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Development of a contralateral epidural haematoma during or immediately after cranial surgery is a well-described entity. However, in a case of acute subdural haematoma where the brain is usually tense, postoperative development of contralateral extradural haematoma is uncommon. We report two cases of contralateral extradural haematoma after decompressive surgery for acute subdural haematoma. We recommend routine postoperative CT immediately after cranial surgery for head trauma. This would help in timely detection and treatment of such a complication.

BACKGROUND The tethered cord syndrome (TCS) is usually diagnosed in childhood and its symptomatic onset in adult life is not common. In the present study, we analyzed the data of patients who presented with TCS in adulthood with the aim of studying the clinical spectrum and management strategies. CLINICAL MATERIAL Over a 5-year period, 18 adult patients (more than 18 years of age) with TCS were investigated with MRI and were operated on. Patients with adult TCS could be divided into two groups. Group 1 included patients who were asymptomatic in childhood and presented for the first time in adult life (10 patients). The second group was comprised of patients with preexisting static skeletal/neurological deformities who presented in adult life with new or progressive symptoms (eight patients). Eleven patients had cutaneous stigmata, 15 had motor or sensory deficit, nine had back/leg pain, eight had leg atrophy, and six had sphincter disturbances. The most frequent MRI finding was a low lying cord with an intradural and/or extradural lipoma. The cord was detethered surgically and the tethering lesion excised. Pain was usually relieved after surgery (8 out of 9), but only a few patients (2 out of 6) had improvement of sphincter dysfunction. CONCLUSIONS The late presentation of TCS is possibly related to the degree of tethering and the cumulative effect of repeated microtrauma during flexion and extension. Adult patients with persistent back/leg pain and/or neurological or skeletal deformities should be investigated with MRI to establish an early diagnosis. Surgery should be performed in all adult patients with TCS, once the diagnosis is established.

Growing skull fractures are rare complications of head injury, occurring almost exclusively in infants and children under the age of three. A retrospective review at our Institute yielded 41 patients with this entity over a period of 20 years (1975-1995). The age at presentation ranged from less than 1 year to 62 years, with 33 (80.5%) patients being less than 5 years of age. The cause of injury was either a fall from a height (93%) or a road traffic accident. The most common location of a growing skull fracture was either parietal or frontoparietal (56%). One patient had a posterior fossa growing skull fracture. CT scan was performed in 19 patients which demonstrated an underlying porencephalic cyst, hydrocephalus or a cyst communicating with the ventricle. In 5 children, a ventriculo-peritoneal shunt alone was performed. Twenty four patients underwent a duro- and cranioplasty while a duroplasty alone was performed in 8 patients. The material used for cranioplasty included acrylic, wire mesh, steel plates or autologous bone. Three patients died, one due to an anaesthetic complication and two as a result of postoperative meningitis. Post-operative CSF leaks occurred in 3 patients, which were managed by a lumbar drain. Six patients had local wound infection.

BACKGROUND Spinal subarachnoid hematoma (SAH) is uncommon following traumatic injury to the spine. There are few case reports of neurologic deficit secondary to traumatic spinal SAH. CASE DESCRIPTION This 6-year-old boy was injured in a vehicular accident from which he became paraplegic and presented to us 1 week later. Plain X rays were normal and a myelo-computed tomography (CT) scan demonstrated an irregular intradural lesion from D10-L2. The magnetic resonance imaging (MRI) revealed an SAH at D11-12 level, posterior to the cord, which was surgically evacuated. The patient did not improve neurologically. CONCLUSION Significant cord injury and neurologic deficit can occur without obvious abnormalities on plain X rays or CT scan. MRI is very useful in detecting these lesions and can help in their management.

Two cases of spinal intramedullary tuberculous granulomas (tuberculomas) without any bony involvement are reported. The rarity of the occurrence and the magnetic resonance imaging (MRI) findings are discussed. Microsurgical excision and antituberculous treatment produced good results.

Cranial chordomas are extremely rare in childhood with only 25 cases having been reported in the first decade of life. A 6-year-old female child with cranial chordoma is reported. Literature on the subject is reviewed, with special reference to the management, histopathological features and prognosis in childhood chordomas as compared to the adult variety.

The use of wound drains in surgical practice, very often falls into the realm of habit, rather than science. The utility of a prophylactic drain in surgical wounds may be questionable, but this practice is not uncommon, despite complications. We report a case of fatal haemorrhage from the superior sagittal sinus, due to a closed negative suction drain of the craniotomy wound in an infant operated upon for a growing fracture skull.

The standard surgical approaches described for excision of anterior or anterolaterally placed foramen magnum (FM) tumours are the far lateral approach, the extreme lateral approach and the transoral approach. In general the posterior midline approach is considered not suitable for these lesions. We have operated on 27 patients with benign anterior/anterolaterally placed FM tumours in the last 8 years. Thirteen of these were operated via the posterior midline approach. All these 13 patients had large or giant tumours displacing the cervicomedullary region posteriorly and laterally. This allowed adequate access through this approach with minimal handling of neural tissue. For small lesions, the far lateral approach was used. Most of the patients improved significantly neurologically. We recommend the standard midline posterior approach for large/giant FM tumours as the tumour size itself provides enough working space for the surgeon. For small lesions, the far lateral approach is preferred.

Infection with the fungus Cryptococcus neoformans is seen predominantly in two forms: (a) pulmonary and (b) cerebromeningeal. Skeletal cryptococcosis is uncommon. There have been only occasional case reports of thoracic vertebral cryptococcosis presenting as cord compression. A young female had cervical lymphadenopathy diagnosed as tuberculosis by fine needle aspiration cytology (FNAC) and was on antitubercular therapy (ATT) for 5 months. She developed rapidly progressive paraparesis and imaging demonstrated a destructive vertebral body lesion involving T2-3 with a paraspinal abscess producing cord compression. A costotransversectomy with excision of the diseased bone and bone grafting was done. Histopathological examination revealed cryptococcosis. The patient was put on antifungal medication, but expired 2 weeks after surgery. Radiological, magnetic resonance imaging and surgical finding of vertebral cryptococcosis can mimic tuberculosis. The definite diagnosis of cryptococcosis depends upon microscopic identification of the organism. A high index of suspicion leading to early surgical confirmation and institution of anti fungal therapy is necessary to reduce the mortality and morbidity.

A rare case of metastasis to the brain from an urachal carcinoma is reported. Metastasis in the brain developed 7 months after partial cystectomy and radiation therapy. Cranial computed tomography showed a ring-enhancing mass lesion that was excised. A month later, the patient died of distant metastasis.

A patient with a complete fracture dislocation of the C6 vertebra without any neurological deficit is presented. The absence of neurological changes in an area of the spinal canal which is almost completely filled with the spinal cord is remarkable. The mechanism of injury in this patient is believed to be hyper-extension associated with significant axial loading. Hyperextension first ruptured the anterior and the posterior longitudinal ligaments and then injured the pedicles of C6. The associated axial loading resulted in a ‘bursting’ of the posterior elements, thereby providing room for the spinal cord to move dorsally with the avoidance of a major neurological deficit.

A case of bifrontal oligodendroglioma with bilateral posterior communicating artery aneurysms, one symptomatic and the other incidental, is presented. This is the first instance of such a combination. Clipping of the aneurysm, along with partial tumour excision, was performed at the same sitting, successfully. Literature on this association is reviewed and the pathogenesis is discussed.

Isolated involvement of the 5th through 10th cranial nerves, in blunt head trauma, without any other neurological deficit, is extremely rare. Two such cases are reported and relevant literature reviewed. The mechanics of trauma involved and the poor recovery is outlined.

BACKGROUND Intracranial fungal granulomas are uncommon and their pathogenesis, clinical picture, and effectiveness of therapy remains unclear. METHODS Thirty-two cases were studied retrospectively in two groups: (1) Rhinocerebral group (22 cases) had a chronic paranasal sinus (PNS) disease with secondary involvement of skull base, cranial nerves, and/or brain. The granulomas were adherent to dura, firm, avascular, and tough, requiring a knife to cut. (2) Primary intracranial group (10 cases) had no detectable PNS lesion at initial presentation. The granulomas were soft, suckable, and contained pus or necrotic material. RESULTS Postoperative and overall mortality were 37.5% and 50%, respectively. Meningoencephalitis was the most common cause of death. Altered sensorium, pus in the granuloma, and/or severe brain edema were poor prognostic factors. All survivors except four have symptomatic residual or recurrent lesions. CONCLUSION Early diagnosis with MRI or stereotactic biopsy, radical surgery, and high dose and chronic suppressive chemotherapy may improve overall results in these cases.

Thirty eight patients with multiple pyogenic brain abscesses constituted 11% of all the brain abscesses treated during a 12 year period. Sixty per cent (23) of the patients were in the first two decades of life, including 9 (24%) infants. The clinical presentation was similar to brain abscess in general. 21 patients had altered “sensorium” at the time of admission. Otogenic brain abscesses were the commonest (26%), followed by those associated with congenital cyanotic heart disease (18%). The abscesses were invariably large in size. The pus was sterile on culture in 11 (29%) patients, while Staphylococcus aureus was the commonest organism grown in 9 (24%) patients. Aspiration of the pus was required as a life saving measure, to control raised intracranial pressure, in 29 (76%) patients. Twelve (32%) of these patients underwent secondary excision of the abscess capsule. The overall mortality was 32% with failure to control intracranial and systemic infection as the major causes of mortality. Level of consciousness at the time of admission was the most significant factor affecting the outcome. Surgery has a definite therapeutic and life saving role in the management of multiple pyogenic brain abscesses. A systematic treatment plan for multiple abscesses is proposed.

Aneurysmal bone cysts are uncommon bony lesions of the spine. Two such patients are reported in the study. The first patient had involvement of first and second thoracic vertebrae, and a preoperative diagnosis was made possible due to the typical magnetic resonance imaging appearances. A total removal was achieved in two stages. In the second patient the C2 spinous process was involved, and this patient presented as atantoaxial dislocation. Removal of the abnormal tissue and posterior fusion was done. Both the patients showed neurologic improvement. The relevant literature is reviewed.

The authors report a case of a growing fracture of the skull in an elderly woman who remained asymptomatic for over 6 decades and presented at the age of 62 years with symptoms akin to the syndrome of the trephined. Successful duraplasty and cranioplasty were done with disappearance of all symptoms. A brief review of the relevant literature is also presented.

Tuberculous atlanto-axial dislocation (AAD) is extremely rare. Of 145 cases of AAD treated at our institute, 15 were due to tuberculosis. Neck pain or restricted neck movements were the predominant presenting features. Based on the radiological findings the disease was staged: stage I, AAD with retropharyngeal mass or abscess (RPAB) and normal bony architecture (5 cases); stage II, AAD with or without RPAB and with minimal bony destruction (4 cases); stage III, AAD with or without RPAB and with gross bony destruction (6 cases). Conservative treatment was effective in stage I and for some patients in stage II, while patients in stage III needed surgery. CT was helpful in early diagnosis, staging, treatment planning and follow-up of these patients.

Non-missile penetrating injuries of the spine accounted for 7% of all spinal injuries admitted to this Institute during the last 10 years. Young males were most commonly affected and 73% of the injuries involved the upper dorsal und cervical spine. They presented with varying degrees of neurological deficit. Plains x-rays revealed the bony injury and/or the retained foreign body satisfactorily. Myelography (with or without CT scan) was performed in patients with progressive neurological deterioration and those not responding to conservative therapy. Surgery remained the mainstay of treatment and improved neurological function in 7 out of 9 cases. Conservative management resulted in complications such as persistent CSF fistula, uncontrolled fulminant meningitis and septicaemia, with 100% mortality. Early surgical intervention is, therefore, recommended in all penetrating injuries of the spine.

Forty one cases of subdural empyema treated between 1977 and 1988 at the Postgraduate Institute of Medical Education and Research. Chandigarh, have been analysed. The patients ranged from 9 days to 80 years of age. There were 22 children, including 11 infants. Fever, altered sensorium and seizures were the most common symptoms present for 1 day to 6 months. Otogenic infection was the commonest aetiological factor followed by postoperative and posttraumatic causes. Thirty seven patients had supratentorial empyemas, including 4 with parafalcine collections, three had infratentorial empyemas, and in one there was extension of the empyema from the supratentorial to the infratentorial compartment. Therapeutic modalities used included percutaneous needle aspirations in infants and burr hole evacuation and craniotomies in adults. A wide spectrum of organisms was detected. Mortality in this series was 24%, which was mainly attributable to the deteriorated neurological status prior to treatment. A detailed review of the literature has been given, highlighting various controversies in the management of SDE. Important prognostic factors and a treatment plan are suggested.

Three cases of spinal cord compression due to solitary osteochondroma of the spine are reported. The rarity and benign nature of the tumour is stressed. Other reported cases are reviewed.

Summary A rare case of Ewing's sarcoma, originating primarily in the spinal epidural space is reported. Only five similar case reports are available in the English literature. Full recovery from a state of complete paraplegia, due to malignant compression, local recurrence without distant metastases and the longest survival of more than three years and six months, makes a unique combination. Pathology and therapy are briefly discussed and the pertinent literature reviewed.

Four cases of intradural extramedullary tuberculous spinal granulomas without bony involvement are presented. Both, the rarity of the disease, as well as the successful microsurgical resection with good recovery prompted this report. The pathogenesis with the controversies therein, is discussed and pertinent literature is reviewed.

Summary A case of two infected cystic epidermoids of the right cerebellar hemisphere is reported. One of the cysts showed peripheral contrast enhancement on CT. Relevant literature regarding the pathogenesis and CT diagnosis is reviewed.

A case of infected intradural extramedullary hydatid cyst at foramen magnum with recurrent spinomedullary compression is described. The diagnosis was based on operation and histopathology. So far, no case of extraparenchymatous multiple cysts with cervicomedullary compression has been described in literature. Infection within an intact cyst is extremely rare.

A case of brain abscess developing 2 weeks after insertion of skull tongs is reported. The abscess was treated with aspiration and appropriate antibiotic therapy and its complete resolution was confirmed by CT scan. The pathogenesis, through retrograde spread of superficial infection to durocortical veins, is discussed in the light of serial CT scans at different stages of formation and treatment of the abscess.

A rare case of congenital intramedullary ependymal cyst of the dorsal cord in a 7-year-old boy associated with kyphoscoliosis and rachidian malformations of the dorsal spine is reported. Myelography suggested an intramedullary lesion. The posterior location and presence of a clear plane of cleavage from the medullary tissue enabled total enucleation of the cyst. Histological differentiation from other similar intradural cysts is discussed and the relevant literature is reviewed. This is the fifth such case reported in the literature.