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While being considered a simple procedure among the wide spectrum of neurosurgical procedures, the surgical management of chronic subdural hematoma (SDH) still possesses a degree of variability. Present concepts of production versus absorption of chronic SDH fluid has led to practitioners differing in the use of drains, the treatment of inner membrane, the flushing of the subdural cavity, and the perioperative decision making for cases with comorbidities and a history of anticoagulant/antiplatelet usage. In this article, we present the management of chronic SDH over a period of 15 months using the principles followed at our center. In 60 patients of chronic SDH, with the use of drains, we waited for radiological demonstration of brain expansion before drain removal and discharge. In our experience, this has led to better prognostication and very low recurrence rates, particularly in patients with comorbidities and on anticoagulant/ antiplatelet medication.

Introduction: The computed tomography (CT) guided stereotactic biopsy (STB) is considered as method of choice for biopsy of intracranial mass lesions. However, it's disadvantages are frame fixation, time requirement for transportation between CT scan suit to the operation theater with added much higher equipment cost in the relatively resource scarred developing country. Ultrasound-guided biopsy (USGB) is relatively simpler, economical, less time consuming, and real-time procedure. Clinical Materials and Methods: Thirty-seven consecutively admitted patients with supratentorial brain tumors, who underwent biopsy of the lesion using CT compatible stereotactic and ultrasound-guided (USGB) procedure formed cohort of the study. Based on location and size of the lesions, the cases were divided into two groups, superficial and deep. Twenty-two patients underwent ultrasound-guided biopsy and 15 with STB. Results: The diagnostic yield of STB was 93% and 91% for ultrasound-guided biopsy. The mean operation time of STB group was 149.00 min and 94 min for USGB, which was statistically significant. Two cases in each group developed hematoma; however, one case in USGB group needed surgical evacuation. The real-time monitoring detected two hematoma intraoperatively, which were further also confirmed on postoperative CT scan head. Conclusions: The ultrasound-guided biopsy procedure (USGB) was simple, relatively shorter time-consuming procedure and equally efficacious and utilizing economical equipment and can act as a safer alternative to CT STB process for biopsy of the intracranial mass lesion. Furthermore, USGB also provided intra-operative real-time monitoring, which provided clue for close monitoring in the postoperative period after completion of biopsy to look for development of fresh hematoma development not only at the biopsy site but also along the biopsy track and adjoining area. Perhaps, a longer period of ultrasonic monitoring following the procedure would be of greater help to detect hematoma formation, which is one of the most common complications of the biopsy procedure.

A 28-year-old male patient presented to us with bilateral frontal hyperostosis associated with a small unilateral frontal intracranial meningioma. He underwent successful excision of the involved bone and repair of the large cranial defect using a titanium mesh. Histological examination revealed tumor infiltration of the overlying bone. Surgical challenges in the management of such a case are also discussed.

Background Chronic renal failure in neurosurgical patients is not uncommon especially in the setting of hemorrhagic stroke. However, unfamiliarity with the syndrome of increased ICP during dialysis in these cases can lead a novice into the Bermuda Triangle. neurosurgeons prognosticating a patient with an ICH are often left in a state of ambiguity when the baseline blood reports reveal a deranged kidney function profile. To compound matters, Dialysis Disequilibrium syndrome presents with symptoms of raised intracranial pressure like nausea, headache, and vomiting and may even fatal in such cases. Case description We describe a 64 yr old gentleman with right basal ganglia bleed who also had chronic kidney failure at presentation. An ICP monitor was placed in this case and dialysis was carried out along with anti-edema measures such as Mannitol with input-output and serum electrolyte monitoring. The ICP monitor showed a sudden rise in ICP during the dialysis sessions and this was reproducible over 3 such sessions. Eventually, further such sessions were stopped and the patient was managed with osmotic diuretics, antiepileptics. The eventual CT scan also did not show any sign of increased hematoma or mass effect thus pointing to a different mechanism of increase of the same. Conclusion Too often neurosurgeons are faced with cases that may demand knowledge of a disease that may affect the neurological outcome. Avoiding high urea gradients during the procedure, minimizing the dialysis dose and isolated ultrafiltration may be the ideal approach.

Background The papillary tumor of the pineal region (PTPR) is a distinct clinicopathologic entity, the exact biological behavior of which is not known. Finding In the present report we describe 3 additional cases of PTPR because of its rarity. During a study period of 4 years (between January 2003 and December 2006), we diagnosed three cases of papillary tumor of the pineal region (PTPR). Clinico-radio-pathologic examination was done and follow-up was assessed. Microscopically, all 3 cases showed uniform morphology and consisted of papillary and solid areas. Immunohistochemistry showed strong and diffuse positivity for synaptophysin, NSE, chromogranin A, S-100 protein, MAP-2 and cytokeratin. Conclusion PTPR is a distinct entity and needs to be differentiated from other tumors of the pineal region as the biological behavior of this tumor is not fully understood. Radiologically this tumor can sometimes be misdiagnosed as tectal glioma.

Objectives Complete removal of a brain tumor without inflicting neurological deficits is a desirable end result in neurosurgical practice. Currently no prospective randomized surgical series in the literature exists comparing tumor resection under general versus local anesthesia awake surgery may achieve more aggressive tumor resection and minimize postoperative neurological morbidity. Patient and methods We thence conducted a prospective randomized comparative study of results of surgery under awake versus surgery under general anesthesia for intrinsic eloquent area lesions. Fifty-three patients with intrinsic brain tumors in eloquent areas were prospectively randomized (26 patients in awake group and 27 for surgery under general anesthesia). At 3 months follow up, 23% patients in awake group had permanent deficits compared to 14.8% in GA group. Results More than 90% tumor excision was observed in 57% patients in awake group versus 73.7% in GA group. Conclusions The mean operative time, blood loss was found to be was found to be less in GA group patients than in awake group. Better tumor cytoreduction, neurological improvement was seen in GA group (motor improvement in 35.7%, speech improvement in 62.5%) than in awake group patients (motor improvement in 18.7%, speech improvement in 14.3%).

Lhermitte-Duclos disease (LDD) is a rare cerebellar lesion with features of both malformation and benign neoplasm. However, the fundamental nature of the entity, its pathogenesis, and the exact genetic alterations remain unknown. We describe a rare case of bilateral LDD with cerebellar ectopia and presyrinx spinal cord changes. Bilaterality of lesions should argue against a neoplastic origin and support a hamartomatous origin.

Intracranial aneurysms are rare in children and have different epidemiological, clinical, and morphological characteristics and outcome from those in adults. We analyzed demographic, clinical, radiologic features, treatment, and outcome in 55 patients

Background Trans-cranial Doppler (TCD) studies after head injury have been done in the first 24 hours after injury and do not specify the exact interval between injury and time of recordings. We have studied cerebral blood flow changes in patients with severe head injury using serial TCD starting within 6 hours after trauma, and present our findings and its correlation with clinical outcome. Methods Thirty-two patients with closed severe brain injuries formed the study group. Six-hourly serial TCD studies were done starting within 6 hours after trauma until 48 hours after trauma or death of the patient, whichever was earlier. Flow velocities of the extracranial internal carotid ( V EC-ICA ) and middle cerebral artery ( V MCA ) were recorded to identify vasospasm, hyperemia, or oligemia. Serial changes in flow velocities were correlated with the clinical outcome of the patients at 12 months' follow-up after injury. Result Oligemia (n = 30) and vasospasm (n = 2) were the earliest changes observed within 6 hours of trauma. In the oligemia group, persistent oligemia (n = 14), hyperemia (n = 6), normal flow velocity (n = 5), and vasospasm developing within 24 hours (n = 5) were observed. Eight patients developed vasospasm after 24 hours. All patients with persistent oligemia and vasospasm developing within 24 hours had poor outcome. Conclusion Oligemia is the most common change within 6 hours of head injury. Persistence of oligemia beyond 24 hours is associated with poor outcome. Early (within 24 hours posttrauma) onset of vasospasm is associated with poor outcome; however, delayed (>24 hours after trauma) vasospasm is not associated with poor outcome.

Arachnoid cysts are benign developmental cysts occurring most commonly in the middle fossa. Posterior fossa arachnoid cysts are less common, with retroclival arachnoid cysts especially in the pediatric age group being rare. We present a case of a retroclival interpeduncular farachnoid cyst in a 10-year-old boy who presented with left-sided ptosis and episodes of hysterical breathlessness. The surgical treatment involved endoscopic assisted microsurgical excision of the cyst and the child made an uneventful and complete recovery with complete cessation of breathlessness. The clinical presentation, etiopathogenesis, imaging characteristics and treatment modalities are discussed and the relevant literature reviewed.

Objective: The purpose of this study was to investigate the recurrence pattern and significance of various clinical and histological features as predictors of recurrence in pediatric craniopharyngiomas. Methods: A series of 116 pediatric craniopharyngiomas (68 boys and 48 girls; age range, 1.6-18 years) was reviewed. Mean follow-up period was 18.53 months. Tumors recurred in 15 patients within 96 months [mean recurrence-free survival (RFS), 12.67 months]. Of the recurrence cases, 2 had complete (mean RFS, 16 months) and 13 had subtotal tumor excision (mean RFS, 9.03 months). Histologically, an adamantinous pattern was seen in 95% of cases, whereas a papillary pattern was noted in 5%. Brain tissue was included in 41 cases. In 32 of 41 cases, brain invasion was noted, and all were of adamantinous histology. No correlation was noted of histopathological subtyping or brain invasion with recurrence. Conclusions: The significant clinical factors associated with recurrence included extent of resection, tumor size >4 cm, and cystic tumors.

Background: Presence of heterotopic dysplastic renal tissue in the lumbosacral region is an extremely uncommon condition. Case report: We report the first case of diastematomyelia associated with ectopic renal tissue. A 10-month-old male child presented with lipomeningomyelocele associated with spina bifida in the lumbosacral region, and the lipoma was excised. Imaging of the spine at 5 years of age showed spina bifida, bony diastematomyelia, lipomeningomyelocele and a small intraspinal cystic lesion. The boy was then operated upon at the age of 5 years, and histopathological examination of the cystic lesion revealed ectopic dysplastic renal tissue.

Object. The purpose of this paper was to assess the early complications, defined as occurring within 1 year, following gamma knife radiosurgery (GKS) for the treatment of intracranial meningiomas. Methods. Seventy-seven of 306 patients undergoing GKS in the last 2.5 years harbored meningiomas. There were 35 men and 42 women with a mean age of 32.4 years (range 10–80 years). Tumor volume ranged from 0.35 to 28.6 cm3 (mean 7.9 cm3). Gamma knife radiosurgery was the primary therapy in 28 patients and followed surgery in 49 patients. There were 50 basal and 27 nonbasal meningiomas. The most common sites were parasagittal (23 patients) and cerebellopontine angle (14 patients). Ten to 15 Gy was administered to the tumor margins. Clinical and radiological follow up with a mean duration of 122 months was available in 40 patients. Seizures and increased headache were found in five and four patients, respectively. A temporary worsening of hemiparesis was seen in two patients (both with parasagittal tumors). One patient with a cavernous sinus meningioma developed a herpes labialis eruption. Perilesional edema was demonstrated in nine patients and was symptomatic in six. Six (22%) of the 27 patients with nonbasal tumors had edema (all parasagittal) and four patients were symptomatic. Only three (6%) of the 50 basal meningiomas had edema, and only one patient was symptomatic. The occurence of edema did not correlate with tumor volume, margin or maximum dose, or with radiation received by adjacent brain. A reduction in tumor size was seen in seven patients. In one patient a new recurrent lesion developed adjacent to the previously treated tumor. Conclusions. Although GKS provides good results for selected patients with meningiomas, caution is required in treating patients with parasagittal tumors as the incidence of perilesional edema is considerable.

To study the effect of raised intracranial pressure (ICP)-induced alterations in gastric emptying, and their modulation by pharmacological interventions, an experimental model was standardized in rats. A test meal of methylcellulose and phenol red was administered intragastrically. ICP was raised to 40, 60 and 80 mmHg by connecting a buffered saline pressure head to an intracerebroventricular (i.c.v.) cannula. Gastric emptying was estimated after killing the animals, from the residual stomach phenol red content. Inhibition of gastric emptying was observed when ICP was raised, the maximum being at 80 mmHg ICP (percent gastric emptying 26.5%+/-2.8 vs. 83.4+/-4.7 in sham-ICP). Pretreatment with clonidine, prazosin or ondansetron did not modify the raised ICP-induced inhibition of gastric emptying. Cisapride was ineffective at 1 mg/kg but caused a partial reversal at the 5- and 10-mg/kg doses (46.9+/-3.1% and 42.6+/-4.0%, respectively). Carbachol at a lower dose of 0.1 mg/kg i.p., produced a greater reversal (78.3+/-6.0%) than did the high dose (52.8+/-4.1). Bretylium partially reversed the inhibition of gastric emptying (45.7+/-4.3%). The protective effect of carbachol and cisapride suggests that suppression of vagal activity due to increased ICP may play an important role in the inhibition of gastric emptying due to intracranial hyper-tension.

The bacteriological and clinical findings of 18 cases of brain abscess are presented. Identification and antimicrobial susceptibility of anaerobic strains was performed both by conventional methods and the newer RapID ANA II panel and E-test methods, respectively. Characterization of the anaerobic isolates was done by restriction fragment length polymorphism (RFLP). Anaerobic or aerobic organisms alone were recovered in three (16.6%), and mixed aerobic and anaerobic in another three (16.6%) patients. There were nine anaerobic isolates. The predominant anaerobes were Prevotella melaninogenicus (four isolates), Bacteroides preacutus (three isolates), Fusobacterium nucleatum and Peptostreptococcus sp. (one isolate each). A total of six aerobic isolates, all of which were Gram-positive cocci were recovered. All the anaerobic isolates were susceptible to metronidazole, but two isolates of P. melaninogenicus were resistant to penicillin. There was complete agreement between the identification based on biochemical profiles and RFLP patterns. These findings indicate the microbial complexity of brain abscess and the need to target antimicrobial therapy against both the aerobic and anaerobic components of infection.

Background: Spinal dural arteriovenous fistula (SDAVF) is a common type of spinal vascular lesion. However, there has not been any published study on its clinico-radiological characteristics or surgical outcome from India. Aim: The aim of this study was to determine the clinico-radiological features of patients with SDAVF, outcomes following surgical ligation of the fistula and the various factors involved. Materials and Methods: Patients who were operated for SDAVF were studied for demographic details, symptoms, clinical severity, radiological features and neurological outcome in the form of improvement in gait disability grades. Appropriate statistical tests were performed. Results: There were 22 (19 males, 3 females) patients of SDAVF who underwent surgical ligation with a mean age of 55 years. The mean duration of symptoms at presentation was 15 months. Three patients had acute onset while the rest had insidious onset of symptoms. Out of the 22 patients, 11 (50%) had motor weakness as the first symptom, 13 (59%) were bedridden and 19 (86.4%) had bladder involvement at presentation. Thirteen patients had fistulae in thoracic spine, whereas eight had fistulae in the lumbar spine. All had a favorable outcome in the form of at least non-progression of gait disability (14 had improvement while 8 had stabilized). The improvement was non-significantly associated with younger age, acute onset, ambulant status and fistula below T9. It was inversely associated with pain as the first symptom and fluctuant clinical course. Conclusion: Surgical occlusion of SDAVF is usually associated with either improvement or stabilization of motor weakness.

To systematically evaluate the current evidence on the safety and efficacy of stem cell therapy (SCT) in stress urinary incontinence (SUI) to allow objective comparison with existing surgical techniques.Systematic literature search of Medline from years 1946-2012 using terms: "stem", "cell", "stress", "urinary", and "incontinence". Included studies presented empirical data on the treatment of SUI using SCT.adverse events, incontinence, quality of life, urodynamic, transurethral ultrasound and urethral EMG findings.Eight studies met inclusion criteria (seven observational and one randomized). Quality score: median 10.75 of 20 (range 2-12.5). Adverse events: one patient had bladder perforation and two procedures could not be completed due to pain. Temporary urinary retention and cystitis were also reported. Incontinence score: Four studies describe significant improvement. Quality of life: significant improvement in four studies. Urodynamic outcomes: four studies show significant improvement in contractility of urethral sphincter; three studies demonstrate no change in bladder capacity and significant reduction in residual volume; significant improvement in urinary flow three studies, although two found no difference; increase in leak point pressure and detrusor pressure in three studies. Urethral ultrasound: three studies found significant increases in rhabdosphincter thickness and contractility. Urethral EMG: two studies found significant increases in the EMG at rest and at contraction.Data suggest that SC treatment for SUI is safe and effective in the short term. However, the quality and maturity of the data are limited. Robust data from better quality studies comparing this to current surgical techniques are needed.

We report herein a rare case of epithelioid sarcoma, in a 39-year old lady involving the sciatic nerve. Clinically and radiologically it stimulated a nerve sheath tumor. Involvement of a nerve by an epithelioid sarcoma is extremely uncommon. To the best of our knowledge, this is the first case of an epithelioid sarcoma involving the sciatic nerve and needs documentation.

Intracranial aneurysms are rarely present in the paediatric age group, and such aneurysms within the anterior circulation are even more rare. Intracranial aneurysms in children differ from adult aneurysms in size, distribution, and incidence of symptoms. We report a 3-year-old girl with an anterior communicating artery aneurysm, who presented with subarachnoid haemorrhage. The patient underwent a pterional craniotomy and clipping of the aneurysm. The postoperative period was uneventful. We review the literature and discuss the characteristics of aneurysms in early childhood.

Ophthalmic segment aneurysms account for about 5% of all intracranial aneurysms. Anatomical complexity of the paraclinoid region makes surgical management of aneurysms arising from the ophthalmic segment challenging. This study was carried out to assess the presenting features, complications and outcomes after surgical treatment of ophthalmic segment aneurysms. The authors retrospectively analysed the clinical records of patients with ophthalmic aneurysms treated at our Institute from January 2001 to September 2008, which constituted about 9% (78/850) of all intracranial aneurysms. Of the 78 ophthalmic segment aneurysms, six patients (8%) had giant aneurysms and 19 (24%) patients had multiple aneurysms. Fifty-six patients underwent microsurgery, with direct clipping in most. The mean age was 42 years (range 12-75 years) and the mean follow-up was 8 months (range, 2-93 months). A good outcome was achieved in 46 (83%) patients (Glasgow Outcome Scale [GOS] score 4-5) and 17% had a poor outcome (GOS score 1-3) at last follow-up. The overall complication rate was 21% (12/56), most of which were transient complications, with 3.5% (2/56) mortality. Direct microsurgical clipping remains our preferred treatment approach, whenever possible, for ophthalmic segment aneurysms. This surgery has an acceptable complication rate and leads to a good outcome in more than 80% of patients with ophthalmic aneurysms. Use of modern microsurgical instrumentation and endovascular adjuncts can further reduce the surgical morbidity associated with these vascular lesions.

Lymphocytic hypophysitis commonly occurs in females in peripartum period but several unusual presentations have been reported. Here we report a rare case of recurrent lymphocytic hypophysitis in a woman who had subtotal adrenalectomy for hypercortisolism 27 years back. Polyglandular autoimmune endocrinopathy with an uncommon combination of Cushing's syndrome and recurrent hypophysitis is a strong possibility in this case. Treatment with steroids has been found to have beneficial effect.

The study has been undertaken to document the clinicopathological features of 12 cases of chordoid meningioma, operated at All India Institute of Medical Sciences during 1996 to June 2005.Clinical information was retrieved from the records of our Neurosurgery Department. The cases were stained with HE, Periodic Acid Schiff (PAS) with and without diastase, mucicarmine, giemsa, toluidine blue, alcian blue, reticulin and Masson trichrome. Immunohistochemistry for pancytokeratin, epithelial membrane antigen, vimentin, glial fibrillary acidic protein, MIB-1, Leucocyte common antigen (LCA), CD-3 and CD-20 was done in all cases.The age ranged from 12-67 years (mean 34.2 years) and three of them occurred in18 years. Male to female ratio was 1:1.4. The duration of symptoms varied from 3.5 months to 5 years (mean 14.1 months). No systemic symptoms were noted. The location of tumor in eight cases was in the supratentorial and rest four in the infratentorial compartments. Interestingly, two cases were in intraventricular location, one in the lateral ventricle and other in the fourth ventricle. Microscopic examination showed lobulation with chordoid elements constituting95% of the entire tumor area in 11 of the total 12 cases. In one case, chordoid pattern constituted about 30% of the total tumor area; the rest was predominant meningothelial (60%). Mild to severe lymphoplasmacytic cell infiltrate was present in all cases. The histochemical stains showed the pattern of acidic mucin and interestingly revealed the presence of mast cells both in connective tissue stroma and epithelial cell islands. The inflammatory infiltrate was B-cell predominant. MIB-1 labeling index was low (2%) in all cases except two, which showed LI of 6% and 8%. Strong diffuse immunoreactivity for vimentin and focal positivity for epithelial membrane antigen was noted in all cases.Chordoid meningiomas are predominantly tumors of young adults with predilection for supratentorial location. Intraventricular location, absence of systemic manifestations despite the presence of abundant B-lymphocytes, presence of mast cells and low MIB-1 LI are some of the interesting findings in the present series, which need documentation. Hence, larger number of cases with adequate follow-up data need to be studied further to establish the clinical significance of this variant.

Subfrontal schwannomas are rare intracranial tumors. Most of them are associated with hyposmia/anosmia. The source of origin of these tumors is still incompletely understood. We report a 23-year-old male who presented with recurrent focal motor seizures, but had no hyposmia. The tumor was completely removed by a subfrontal approach. Relevant literature has been reviewed.

The aim of this study was to investigate the recurrence patterns and significance of various clinical and histological features as predictors of recurrence in craniopharyngiomas. A series of 234 craniopharyngiomas (156 males, 78 females; age range 1.6-65 years) was reviewed. The mean follow-up period was 18.53 months (range 1-120 months). Peri-operative mortality was 7.4% and tumor recurrence was observed in 26 patients (20.3%). Of the patients with recurrence, one had total tumor excision (recurrence-free survival (RFS) 14 months), four had near-total excision (mean RFS 18.2 months) and 21 had subtotal tumor excision (RFS for symptomatic recurrence 7.1 months). Histologically, an adamantinous pattern was seen in 81.4% of cases and a papillary pattern was seen in 18.6%. Brain tissue was included in 67 cases and brain invasion was noted in 44 (all were of adamantinous histology). No correlation was noted between histopathological subtyping or brain invasion and recurrence. The significant clinical factors predictive of recurrence included the extent of resection, tumor size greater than 4 cm and cystic tumors.

The authors report seven uncommon cases of paraganglioma of the cauda equina region with reference to their clinical, radiological, and pathological findings. The common presenting symptoms in all the patients were low backache with radiation to both thighs, sensory and motor deficits in four patients, and urinary retention in three patients. One patient presented with ataxia and superficial sidrosis of the brain. Magnetic resonance imaging (MRI) revealed well-circumscribed lesions that were isointense on T1- and T2-weighted images with flow voids. All the tumors were well circumscribed and could be excised completely; however, one recurred. Histological examination revealed a classic “zellballen” pattern in four tumors. Two mimicked ependymoma but were confirmed as paraganglioma by immunohistochemistry. MIB-1 LI was low in all the tumors. Thus, there were no identifying clinical or radiological features that helped in differentiating paraganglioma from other common tumors, such as ependymoma or neurinoma, in this region, and preoperative diagnosis was not possible in any of the cases. Morphologic features and immunohistochemical analysis proved to be the mainstay of arriving at a correct diagnosis. This report highlights the significance of important morphologic features and immunohistochemistry in the diagnosis of paraganglioma at this unusual site.

We report a case of surgically proven giant neurocysticercosis (NCC). MR imaging revealed an unusually large solitary parenchymal cystic lesion showing signal intensity similar to CSF on all pulse sequences, with internal septations and a small nodule in the anterior aspect of this lesion compatible with this diagnosis. Identification of a scolex in a cystic lesion with CSF intensity plays a key role in the diagnosis of NCC. The presence of internal septations is an atypical feature.

Foramen magnum tumors, especially those located ventrally, are surgically challenging. We studied clinical and surgical details of extramedullary tumors located in the region of the foramen magnum.A series of 30 cases of extramedullary tumors at the foramen magnum, operated over a period of 8 years is presented.There were 10 neurofibromas, 8 meningiomas, 6 chordomas, 2 tuberculomas and 4 miscellaneous tumors. The clinical profile consisted of sensory symptoms in all the patients, quadriparesis in 24, lower cranial nerve affection in 8 and sphincter disturbances in 6 patients. The surgical approaches consisted of an extreme lateral approach in 10, a posterior or posterolateral approach in 18 and a per-oral route in 2 cases. Total excision of the tumor was performed in 24 and a subtotal excision of the tumor was done in 6 cases. Two patients died, one due to meningitis and the other due to chest infection. Eight other patients had complications like CSF leak, meningitis, pseudomeningocele, laryngeal edema, and transient worsening of neurological deficits.Foramen magnum tumors have long been regarded as difficult lesions both in terms of diagnosis and management. However, with the availability of MR imaging, newer surgical techniques and skull basal exposures, the excision of these lesions is becoming easier and safer.

A 21-year-old male presented with sudden onset of right-sided third nerve paresis. Angiogram showed a fenestrated posterior communication artery on the right side and no other vascular anomalies. There was no other lesion that could suggest a cause for the third nerve weakness. Fenestration of the posterior communicating artery has not been reported till date. The case is discussed and the literature on the subject is reviewed.

Giant vertebrobasilar (VB) junction aneurysms are uncommon aneurysms, especially those associated with multiple aneurysms of the posterior circulation. We report two cases, one with a small and a giant aneurysm of the VB junction which were surgically clipped; and the other with a small left anterior inferior cerebellar artery (AICA) aneurysm which resolved spontaneously. The patient, however, developed a de-novo giant VB junction aneurysm, which was detected on a follow-up angiogram. This aneurysm was treated by surgical clipping. The clinical features, angiographic considerations and surgical treatment of such rare conditions are discussed and the relevant literature reviewed.

The August 2002 COM. A 21-year-old male presented with a single episode of generalized tonic clonic seizures. Radiology revealed a cystic tumor with mural nodule suggestive of a pilocytic astrocytoma. However, histopathological examination and electron microscopy revealed features of an intracerebral schwannoma. Therefore, although rare, in an intracerebral cystic lesion with mural nodule, the possibility of an intracerebral schwannoma should be entertained. This is important because this is a benign tumor with favourable response to resection.

Placement of lumboperitoneal (LP) shunt as a surgical treatment for benign intracranial hypertension (BIH) is generally a safe procedure, with complications like mechanical failure, overdrainage and infections. Subarachnoid hemorrhage and intracerebral hematoma were seen after lumboperitoneal shunt in a patient having BIH. These complications were the cause of the patient's deterioration. After removal of the hematoma and performing a decompressive procedure, patient's neurological condition improved. The clinical features, investigations and clinical course are described and the literature reviewed.

Obstetrical brachial plexus palsy (OBPP) occurs as sequelae of birth-related trauma, antenatal and parturition related complications. It is associated with varying degrees of functional disability. Electrodiagnostic studies (EDS) are an adjunctive tool and help to localise and prognosticate the outcome of OBPP.Fourteen children, presenting with OBPP to the Clinical Neurophysiology Lab, were analyzed. Details of birth history were obtained, and EDS were performed to characterize the lesion.The age ranged from one month to one year. Ten had unilateral and four bilateral brachial palsy. On EDS, five had pan-plexus, six predominantly upper plexus and three lower plexus involvement. A poor re-innervation pattern on EMG correlated with inadequate recovery.OBPP, a condition associated with considerable disability, needs to be prevented. Electrodiagnostic studies are a useful adjunctive tool for characterizing the site of injury and prognostication.

Recurrence and progression to higher grade lesions are characteristic of the clinical course of astrocytic tumours. Though p53 gene mutation is an important initiating event in astrocytic tumourigenesis, its role in malignant progression remains controversial. We have therefore analysed p53 protein expression in paired histological samples from 48 cases of astrocytic tumours and their recurrences--29 diffuse astrocytoma, 10 anaplastic astrocytoma and 14 glioblastoma multiforme (GBM). Malignant progression at recurrence was noted in 93% of diffuse and 64% of anaplastic astrocytomas. An association was observed of p53 protein immunopositivity and malignant progression at recurrence. Thus, 27 of 48 (56%) primary tumours were initially p53 positive, while in recurrent tumours associated with malignant progression this frequency increased to 71% (34/48 cases). This was because seven of the 13 cases (4/8 diffuse and 3/5 anaplastic astrocytoma) that were initially p53 negative acquired immunopositivity on malignant progression at recurrence. In contrast, none of the 19 tumours that recurred to the same grade showed any change of p53 status at recurrence. Furthermore recurrence was associated with increase in the percentage of p53 immunopositive cells (p53 labelling index), which was also higher in tumours with progression. This new acquisition of p53 immunopositivity on progression at recurrence has not been documented in earlier studies in English language literature, though increase in p53 LI has been documented. Thus, this study conclusively indicates the role of p53 in malignant progression of astrocytic tumours. Also, it suggests a potential role of p53 LI in predicting malignant progression at recurrence because the highest initial LI was noted in those tumours which progressed to GBM as compared with those which recurred to the same grade or progressed to anaplastic astrocytoma. No correlation could, however, be demonstrated between p53 immunoreactivity and interval to recurrence.

The membranes from 50 cases of chronic subdural haematomas were examined histologically and correlated with the duration of the lesion. Cases were divided into three groups based on duration from time of trauma and/or onset of clinical symptoms to date of surgery - Group I: 1 to 30 days, Group II: 31 to 90 days and Group III: >90 days. Infiltration with eosinophils was observed in the vascularised and hyalinised granulation tissue of the subdural membrane in 30 of the 50 cases (60%). There was a trend to correlation both of the frequency and the extent of eosinophilic infiltration with duration of haematoma. Thus, eosinophils were encountered in about half the cases with duration up to 3 months which increased to 80% in cases with duration more than 3 months. The extent of eosinophilic infiltration (mild, moderate or severe) also appeared to correlate with duration of haematoma in that mild infiltration was more common in Group I cases while moderate to severe infiltration were more frequently observed in Group II and III cases. No correlation was observed of the eosinophilic infiltrate with age and sex of the patients or with presence of other cellular inflammatory components of the membrane. Interestingly, a finding hitherto unreported in English literature was the demonstration of mast cells in 7 of 16 membranes (44%) which had been stained using toluidine blue. It is possible that the eosinophils appear at this unusual site due to chemotactic stimulus abetted by these mast cells as well as lymphocytes and haemosiderin pigment. The eosinophils may have an important role in the repair and healing process of these membranes.

The aim of this study was to evaluate clinical, radiological and pathological features of vertebral osteochondromas with compressive myelopathy and to review the relevant English literature. Osteochondro-mas are common benign bony lesions of long bones but involvement of spine by solitary osteochondroma and its presentation as compressive myelopathy is rare. Most of the literature is in the form of case reports.During a period of 20 years (1980-1999), 10 cases of osteochondromas of the spine were encountered. Clinical, radiological and pathological features were reviewed.The age ranged from 13 to 45 years (mean 25.3 years) and all except 1 were males. In 8 cases the pathology involved the cervical spine and in two cases dorsal spine was involved. All patients presented with progressive motor sensory deficit of 6 months to 30 years duration (mean 3.9 years). Decompressive laminectomy was carried out in all the patients. Fortunately, gradual and complete recovery was observed in all of them.Osteochondromas of the spine are not as rare as reported in the literature. In a young patient of compressive myelopathy this possibility should be considered. Magnetic resonance imaging, computed tomography and CT myelogram are useful in evaluating the size and extent of the lesion for subsequent surgical planning.

The factors influencing early complications following Gamma Knife radiosurgery have not been definitely established. We report a prospective study evaluating the incidence of early complications (occurring within 3 months of radiosurgery) and various factors associated with early complications following stereotactic Gamma Knife radiosurgery for intracranial lesions.Seventy-nine previously unirradiated consecutive adult patients (82 lesions: arteriovenous malformations 35, benign tumors 43, metastases 4) treated by Gamma Knife radiosurgery were studied between May 1997 and August 1998. The median target volume was 4.8 cm(3). The median dose of 15 Gy was prescribed to the 50% isodose. Patients were evaluated clinically and radiologically (with CT/MRI/SPECT) at 3-month intervals for the 1st year and 6 monthly thereafter. Complications were further divided as immediate (occurring within 24 h) or acute (occurring from 1 day to 3 months).Early complications were observed in 19/79 (24.0%) patients. These included immediate in 10 (12.7%) and acute complications in 9 (11.3%) patients and were characterized by headache, nausea/vomiting, vertigo and seizures. No severe early complications were observed. Radiological changes in the form of perilesional edema were seen in 8/82 (9.8%) lesions. Maximum target diameter25 mm was the only factor significantly associated with early complications by univariate analysis (p = 0.0335). Multivariate analysis revealed maximum target diameter25 mm and prescribed dose20 Gy to be significantly associated with early complications (p = 0.0442 and p = 0.0083, respectively).Up to one fourth of the patients undergoing Gamma Knife radiosurgery for intracranial lesions can experience self-limiting early toxicity. The selection of targets with small diameter and volume may reduce the risk of early complications following Gamma Knife radiosurgery.

An experimental study was designed to compare the histological analysis of nerve anastomosis with 10-0 microsurgical sutures and fibrin adhesive. Wistar albino rats' sciatic nerves were transected and repaired either with fibrin adhesive-Beriplast P (M/s Centeon-Cadila Health Care) or with 10-0 monofilament microsutures. Histological assessment was performed at 10, 20, 30, 60 and 90 days after surgery. Functional recovery of the sciatic nerves started at two months and was near normal by three months. Separation of the stumps did not occur in any of the glued nerves. Histological evaluation showed no appreciable difference in the outcome of nerve regeneration after microsurgical repair using sutures or fibrin tissue adhesive. However, inflammation and granuloma formation were appreciated at the suture site, which presented a focal hindrance to myelin and axonal regeneration. Fibrin glueing is attractive for clinical purposes, since it is simpler and less time consuming than suturing.

The authors present a case of spontaneous regression of a posterior fossa, supracerebellar arachnoid cyst causing hydrocephalus in a 7-month-old male child. The patient presented with macrocrania, bulging fontanelle and upgaze paresis of the eyes. There was complete improvement of these symptoms on the morning of the day of surgery without any obvious precipitating factors, including trauma. CT scan showed complete resolution of the cyst and hydrocephalus. The child was doing well at 1 year of follow-up. To the best of our knowledge, this is the first case report of spontaneous resolution of a posterior fossa arachnoid cyst.