International Journal of Neurology and Neurosurgery

  Spinal tuberculosis, also known as Pott’s disease is a common extrapulmonary manifestation of tuberculosis. It commonly involves the dorsal spine as paradiscal lesion with destruction of intervening disc with subligamentous spreading of the pus. Non contagious spinal tuberculosis (TB) involving the cervical, dorsal, lumbar and sacral region are very rare. Till now, only 4 cases have been previously reported in the literature. We report a rare case of skipped multifocal spinal TB involving the whole spine of a 23-year-old immunocompetent male patient. He presented with
back pain and walking difficulty for 5 months with some constitutional symptoms. Initial evaluation with plain radiographs showed collapse of D5 vertebrae with localized angulation. Later on, MRI of the dorsal spine with whole spine screening showed multifocal skipped lesion involving whole spine with presence of huge presacral collection. Percutaneous aspiration of the purulent collection done and tuberculous infection confirmed by Gene Xpert. Patient started anti TB therapy and discharged in an improved state both neurologically and in serological parameters.
He was advised to continue medication for a total of 18 months. Multifocal non contagious spinal TB involving the whole spine is rarely reported in the literature, which considered as one of the most atypical presentations of spinal TB. As a differential diagnosis of multifocal lesion of spine, TB should be considered in our context. 

Keywords: Noncontiguous Multisegment; Skip Lesion; Spinal Tuberculosis. 

  Objective: Several surgical approaches have been proposed for the treatment of colloid cysts, which still remains controversial. Though microsurgical craniotomy is more apt to result in a gross total resection, yet subtotal resections and recurrences occur even with best possible efforts. Off late, endoscopy is emerging as an effective alternative to address various intraventricular lesions. Methods: The study was carried out on 23 patients (Males-14, Females-9) spanning over a period of 8 years. The age group of the patients ranged from 16years-60 years. Depending on the radiological appearance, the procedure was performed via a right or left precoronal burr hole. We aimed for complete resection of the entire cyst, including the cyst wall. Only in situations in which a part of the cyst wall could not be separated from neural or vascular structures, it was coagulated and left in situ. Results: The Follow-up period ranged from a period of 2 months-96 months. All patients were operated by precoronal uniportal transventricular technique without using any navigation system. Twenty two patients were operated by transforaminal approach. One patient required trans-septal approach. Complete excision was possible in 20 cases, while in three patients a small part of cyst was left to avoid venous injury. The operative time ranged between 45 to 100 minutes. Resolution of the symptoms was obtained in all our patients without any mortality. Conclusion: These results show that endoscopy is a safe and effective alternative to the well established approaches of microsurgical removal and stereotactic aspiration with a quicker return to active life and low or negligible direct surgical morbidity. 

Keywords: Neuroendoscopic Excision; Craniotomy; Colloid Cysts.

  Introduction: “Traumatic brain injury (TBI) still represents the leading cause of morbidity and mortality in individuals under the age of 45 yrs.” There is a large potential spectrum of traumatic vascular injury that may occur in isolation or in different combination. We analyze the various types of blunt cerebrovascular injury in thirty head injury patients. Blunt cerebrovascular injury (BCVI) may be overtly present in more than 1% of patients with blunt trauma.2 Aggressive screening strategies uncover injuries in up to 44% of those screened. If not appropriately diagnosed and treated in a timely manner, many such injuries are responsible for significant morbidity and mortality. Aim of the study: To analyze the various types of blunt cerebrovascular injury in head injury patients. Materials and methods: The patients admitted in the neurosurgical ward with vascular injury involving ICA, Vertebrobasilar artery and its primary branches as identified by CT brain, CT Angiogram, MRI scan, MR Angiogram or DSA either alone or in combination, were included in this study depending on the feasibility of investigation. Results: A total of 3770 head injury patients were admitted in Institute of Neurosurgery during the study period. Based on DENVER’S screening criteria about 95 patients were identified as high risk individuals for blunt cerebro vascular injury. Out of these 95 patients only 30 patients were diagnosed and confirmed to have vascular injury by CT angiogram, DSA and through post mortem. Conculsion: Our conclusions are Patients presenting with Raccoon eye (black eye), anterior skull fracture in sagital direction with CT brain findings suggestive of ischemia in the MCA/ACA territory were more likely to have supra clinoid ICA injury, Patients with Battle’s sign, petrous bone fracture in transverse axis and CT brain showing features of ischemia were more likely to have ICA injury, Patients with Battle’s sign, occipital bone fracture extending into the petrous part of temporal bone were more likely to have bilateral ICA or Vertebra basilar artery injury.

Keywords: Traumatic Brain Injury; Blunt Cerebrovascular Injury; Head Injury.

  Introduction: Seizures in CVT can be divided into presenting seizures and early seizures. Presenting seizures are those that occurred at or before confirmation of CVT diagnosis. There is paucity of data in literature about presenting seizures in CVT patients. Aim of the study: To study the clinical profile and risk factors involved in presenting seizures in CVT patients. Materials and Methods: The study is an observational study conducted in department of neurology in a tertiary care centre in South India. The period of study is from August 2017 to July 2018. Cerebral venous thrombosis was confirmed by MRI Brain with MR venography. Demographic data, clinical findings, Neuroimaging findings and risk factors for CVT of patients with presenting seizures were captured. Descriptive statistics were used wherever necessary. Results: 14 patients out of 78 had presenting seizures (17.94%). 8 patients were female (57.1%) and 6 patients were male (42.9%). Mean age in the study group was 37.42± 2.69. Headache was present in 11 patients (78.57%). Seizures were focal in 4 patients (28.57%) and generalized in 10 patients. (71.43%). Superior sagittal sinus was involved in 7 patients (50%). Supratentorial lesion was seen in 13 patients (92.85%). Lesion in frontal lobe was seen in 6 patients (42.85%). Conclusion: The presenting seizures were more common in females, more frequent in patients with multiple risk factors, more common with frontal lobe involvement and more common with superior sagittal sinus involvement. Incidence of seizures is high in patients with any supratentorial lesion. 

Keywords: CVT; Presenting Seizures. 

  Introduction: The tentorium is a membrane which covers the cerebellum. It separates the cerebrum from the cerebellum. The term tentorium was first coined by Winslow. The tentorium is attached to the temporal, occipital, and sphenoid bones. All of the tentorial margins, except the free edges bordering the incisura, are rigidly attached to the cranium. The anterior border is attached to the petrous ridge. The lateral and posterior borders are attached to the inner surface of the occipital and temporal bones along the internal occipital protuberance and to the edges of the groove for the transverse sinus. Aim of the Study: To determine the incidence of venous sinuses within the tentorium cerebelli. Identify the location, configuration and size of the sinuses within the tentorium. Materials and Methods: In this study, 100 human cadaveric brains of both male and female that underwent autopsy within 12-48 hrs after death were studied in the year 2016-2018 in Department of Neurosurgery, Government Mohan Kumaramangalam Medical College. Salem. Skullcap was opened in a circular manner. The frontal lobes were lifted after opening the dura mater and the anterior falx was cut. The brain stem was cut axially just above the level of tentorial incisura. Results: Variations of tentorial venous sinus in cadaver cerebellar tentoria were examined in 100 autopsies. Venous sinuses were present in tentorium in 91 (91%) cadavers and absent in 9 cadavers. There were 145 tentorial venous sinuses in 91 cadavers. Of these sinuses, 81 (55.9%) occurred on the left side, 64 (44.1%) occurred on the right side. Conclusion: Incidence of venous sinuses in tentorium cerebelli is 91%. Middle one-third of tentorium cerebelli is the least vascular portion. These findings will be useful for procedures that require sectioning of the tentorium. These sinuses serve as important collateral channels when the straight sinus or torcular herophili is occluded by pathological processes. 

Keywords: Tentorium Cerebelli; Venous Sinus; Skull Injury; Congenital Malformations of the Brain. 

  Context: Lipoprotein (a) is an established risk factor for coronary artery disease but its role as a risk factor for stroke is not established. Aims: To estimate the prevalence of elevated levels of lipoprotein (a) in young patients (18-55 years) with ischemic stroke and to study the association between lipoprotein (a) plasma concentration and carotid atherosclerosis Settings and Design: This observational, cross-sectional, single center study was conductedon 90 young (18-55 years) patients with imaging confirmed ischemic stroke for a duration of 1 year. Lipoprotein (a) samples were taken within 24 hours of presentation to the hospital and values >30mg/dL were considered abnormal. Carotid Doppler was done by a cardiologist unaware of history of patientsl. Patients were divided into two groups: Group A (normal) and Group B (abnormal). Average values of lipoprotein (a) levels in both the groups were taken and compared using appropriate statistical analysis. Results: There were 65 males and 25 females in the study. Prevalence of elevated lipoprotein (a) in the study population was found to be 44.4%. It was more than the other traditional risk factors for stroke. Prevalence of carotid atherosclerosis and carotid stenosis in the study was 41.1% and 31.1% respectively. Elevation of lipoprotein (a) was strongly associated with carotid atherosclerosis (p=0.001). Mean values of lipoprotein (a) were statistically higher in the atherosclerosis group than in no atherosclerosis group (p=0.002). Lipoprotein (a) was positively associated with carotid stenosis in a graded manner but its association with CIMT was not significant. The association of lipoprotein (a) and carotid atherosclerosis was independent of other risk factors.

Conclusion: Lipoprotein (a) is strongly associated with carotid atherosclerosis (especially carotid stenosis) in young patients with ischemic stroke and the association is independent of the traditional risk factors. 

Keywords: Ischemic Stroke; Young Population; Lipoprotein (a); Carotid Atherosclerosis.

Introduction: Head injury is a common reason for an emergency room visit. A large number of people who suffer head injury are predominantly due to road traffic accidents. Other causes of head injury includes fall from height, train traffic accidents and assault. Children do get involved in RTA due to non compliance of the safety measures. Commonest presentation of head injury includes depressed skull fractures, haemorrhage including both extra axial and intra axial, and contusions along with diffuse axanol injury. Majority of the patients involved in head injury require anti-oedema measures and these patients have a significant alterations in their haematological profile post-treatment with anti-oedema measures and this leads on to poor outcome. Aim of the Study: To assess various haematologicalprofile in patients with mild head injury. Materials and Methods: This retrospective study conducted in 2016-2018 in Department of Neurosurgery, Government Mohan Kumaramangalam Medical College, Salem. 45 cases got selected based on the GCS criteria. These patients case sheets were scrutinisedand the following data’s were collected from the case sheets. Age, sex, date of admission, date of surgery (if performed), diagnosis, mode of injury, history of loss of consciousness, vomiting, ENT bleed, seizures, GCS at the time of admission, associated injuries, first CT scan brain findings, other investigations done, haematological profile such as blood glucose, coagulation profile, liver function test, renal function test, and serum electrolytes variations are assessed using standard techniques. Results: In all the patients who were treated for mild head injury with or without antiedema measures, the majority showed metabolic abnormalities. Electrolyte abnormality was present in 14 patients. The altered liver function was present in 15 patients out of the 45 who were treated either in the form of elevated liver enzymes or raised bilirubin levels. Deranged blood sugars were present in more than 50% of the patients and even on continuous monitoring and with insulin therapy, few cases failed to reach glycemic state. 9 Patients of them showed coagulation abnormalities in the form of raised bleeding time, clotting time and with prolonged prothrombin time and INR. Renal parameter abnormality was present in a significant group of patients.

Conclusion: Haematological abnormality was frequently found in patients with mild head injury whether or not they were treated with anti-oedema measures. Although coagulation abnormality was thought to alter the CT findings, only one-third of the deteriorated patients with coagulation abnormality showed positive findings on a CT scan which needs further haematological studies to prove the correlation between the two 

Keywords: Blood Glucose; Coagulation Profile; Liver Function Test; Renal Function Test; CT Scan; Head Injury
 

  Pterion approach is widely accepted as a standard method for clipping of A-com artery aneurysm. With progresses of microscopic instruments and surgical techniques, keyhole approach for clipping of anterior circulation aneurysm is becoming popular. Objectives: To evaluate & compare clinical outcome of surgery after lateral supraorbital subfrontal keyhole and Pterional craniotomy for anterior communicating artery aneurysm. Materials & Method: This study is a retrospective review between supraorbital subfrontal keyhole versus pterional craniotomy for the surgical management of anterior communicating artery aneurysm in 26 patients operated between jan 2014 and jan 2018 in our institute. Results: A total of 26 were operated for A-com aneurysm, 13 patients by lateral supraorbital keyhole 6 (46.15%) male and 7 (53.84%) female and 13 patient by pterional approach 5 (38.46%) male and 8 (61.53%) females. Compared with the pterional approach, keyhole approach showed better outcomes regarding the incidence of craniotomy-related pain, cosmetic look, and patient satisfaction. Conclusion: In our study there was significantly less amount of blood loss, post operative pain, duration of stay and complications in key hole approach. Eyebrow-lateral supraorbital keyhole approach for microsurgical clipping of A-com artery aneurysm gives satisfactory therapeutic outcomes. 

Keywords: keyhole surgery; A-com aneurysm; supraorbital keyhole.

  Introduction: Mlld traumatic brain injury is defined by the American Congress of Rehabilitation Medicine as involving an alteration in consciousness (amnesia or confusion), less than 30 minutes of loss of consciousness, or less than 24 hours of post traumatic amnesia, with focal neurological deficits that may or may not be transient. Materials and Methods: This retrospective study was conducted in 2016-2018 in Department of Neurosurgery, Government Mohan Kumaramangalam Medical College Salem. 45 cases got selected based on the GCS criteria. These patients case sheets were collected from the following data’s were collected from the case sheets. Age, sex, date of admission, date of surgery (if performed), date of death, diagnosis, mode of injury, history of loss of consciousness, vomiting, ENT bleed, seizures, GCS at the time of admission, associated injuries, first CT scan brain findings, other investigations done, opinions obtained from other departments for associated injuries or medical conditions, preliminary investigations, date of deterioration, cause of deterioration as evidenced by supporting investigations or examination findings. Results: Majority of the patient (23 patients) who were admitted with mild head injury and have died had bifrontal or frontal contusions alone or in association with contusions in other areas of the brain. 20 patients had subdural hemorrhage, which includes acute and chronic, 5 patients had extradural hemorrhage, 19 patients had a subarachnoid hemorrhage, 19 patients had skull fractures visible on CT scans and 7 patients had pneumocephalus. Many patients had more than one finding on a CT scan. Conculsion: Focal injuries are those visible injuries limited to a well circumscribed part of the brain whereas diffuse injury is one in which there is no visible macroscopic structural damage to the brain, but associated with widespread dysfunction of the brain. Even in its mildest form, diffuse injury may be assisted only with alterations in neuronal excitability, neurotransmission related injuries and/or receptor related injuries. In its more severe cases it may be associated with structural damage at microscopic levels without any visible mass lesion. 

Keywords: Head Injury; Glass Coma Scale; CT Findings; Fractures
 

  Introduction: Cerebral veins drain the blood into the dural sinuses, which are endothelium-lined channels without valves and enclosed in the leaves of the dura mater. The superior group comprises the superior and inferior sagittal sinus, and the straight, transverse, and sigmoid sinuses superficial veins drain into the superior sagittal and transverse sinuses, and the deep cerebral veins into the straight and transverse sinuses. The confluence of the sinuses (torcular Herophili) results from the junction of superior sagittal, straight, and transverse sinuses and is often asymmetrical. The inferior group drains the basal and medial parts of the undersurface of the brain, the orbits, and the sphenoparietal sinus and collects at the cavernous sinus. Aim of the Study: To assess the drainage pattern in venous sinuses within the tentorium cerebelli in 100 cases of the autopsy. Materials and Methods: In this study, 100 human cadaveric brains of both male and female that underwent autopsy within 12-48 hrs after death were studied in the year 2016-2018 in Department Of Neurosurgery, Government Mohan Kumaramangalam Medical College, Salem. Skullcap was opened in a circular manner. The frontal lobes were lifted after opening the dura mater and the anterior falx was cut. The brain stem was cut axially just above the level of tentorial incisura. Results: In this study, the group - 1: 22 (32%) sinuses were typed A, 40 (58%) sinuses were type B, 7 (10%) sinuses were type C, among the Group 1 sinuses. Of these 69 sinuses, 6 sinuses which were longer in size occupying a small portion of the medial part of middle one-third of tentorium cerebelli along with its course in entire medial one-third of tentorium cerebelli. Among these sinuses, two sinuses were on the right side and eight sinuses were on the left side. All of these sinuses were smaller in size. No branching pattern was observed in Group 2 sinuses. All of these sinuses were observed to drain into the middle one-third of the transverse sinus. The tentorial sinuses of Group 3 were drained into lateral one-third of transverse sinus or to the junction of the transverse sinus and superior petrosal sinus. Venous ring pattern was occupying the entire posterior portion of tentorium cerebelli. This venous ring was bilateral in two cadavers and unilateral in four cadavers. Conclusion: These sinuses serve as important collateral channels when the straight sinus or torcular herophili is occluded by pathological processes. They also play an important role in several vascular and congenital malformations of the brain. 

Keywords: Tentorial Sinuses; Drainage Pattern; Sphenoparietal Sinus; Cavernous Sinus

  Aim: To study the types of brainstem injury and their clinical and radiological presentation and to correlate the macroscopic and microscopic findings with the above clinical and radiological imaging. Materials and methods: 50 patients who sustained fatal head injury and died in our hospital were taken up for this study. Patient’s age, time of injury, mode of injury, level of consciousness, the site of impact of head injury, other associated injuries and survival period were collected. Radiological evidence of fracture, hematoma, contusions, edema, and basal cistern obliteration were noted. At the time of autopsy, the brainstem was examined looking for areas of gross contusion, hematomas and edematous changes. The brainstem specimens were stained with haematoxylin eosin stain and the slides were studied under microscope with low and high power. Brainstem lesions were categorized as primary and secondary depending on macroscopic and microscopic appearance. Conclusion: The study has shown that the lateral impact during trauma has resulted mostly in secondary brainstem lesions. In majority of cases the primary brainstem lesions have been associated with basal skull fractures whereas majority of secondary brainstem lesions were associated with vault fractures. In primary brainstem lesions gross haemorrhagic lesions were seen in dorsal, dorsolateral aspect of midbrain and dorsal aspect of upper pons. In secondary brainstem lesions gross hemorrhagic lesions were seen in the midline and paramedian aspect of tegmentum of midbrain and pons. 

Keywords: brainstem injury; diffuse axonal injury; traumatic brain injury

  Introduction: Cerebral veins drain the blood into the dural sinuses, which are endothelium-lined channels without valves and enclosed in the leaves of the dura mater. The superior group comprises the superior and inferior sagittal sinus, and the straight, transverse, and sigmoid sinuses superficial veins drain into the superior sagittal and transverse sinuses, and the deep cerebral veins into the straight and transverse sinuses. The confluence of the sinuses (torcular Herophili) results from the junction of superior sagittal, straight, and transverse sinuses and is often asymmetrical. The inferior group drains the basal and medial parts of the undersurface of the brain, the orbits, and the sphenoparietal sinus and collects at the cavernous sinus. Aim of the Study: To assess the drainage pattern in venous sinuses within the tentorium cerebelli in 100 cases of the autopsy. Materials and Methods: In this study, 100 human cadaveric brains of both male and female that underwent autopsy within 12-48 hrs after death were studied in the year 2016-2018 in Department Of Neurosurgery, Government Mohan Kumaramangalam Medical College, Salem. Skullcap was opened in a circular manner. The frontal lobes were lifted after opening the dura mater and the anterior falx was cut. The brain stem was cut axially just above the level of tentorial incisura. Results: In this study, the group - 1: 22 (32%) sinuses were typed A, 40 (58%) sinuses were type B, 7 (10%) sinuses were type C, among the Group 1 sinuses. Of these 69 sinuses, 6 sinuses which were longer in size occupying a small portion of the medial part of middle one-third of tentorium cerebelli along with its course in entire medial one-third of tentorium cerebelli. Among these sinuses, two sinuses were on the right side and eight sinuses were on the left side. All of these sinuses were smaller in size. No branching pattern was observed in Group 2 sinuses. All of these sinuses were observed to drain into the middle one-third of the transverse sinus. The tentorial sinuses of Group 3 were drained into lateral one-third of transverse sinus or to the junction of the transverse sinus and superior petrosal sinus. Venous ring pattern was occupying the entire posterior portion of tentorium cerebelli. This venous ring was bilateral in two cadavers and unilateral in four cadavers. Conclusion: These sinuses serve as important collateral channels when the straight sinus or torcular herophili is occluded by pathological processes. They also play an important role in several vascular and congenital malformations of the brain. 

Keywords: Tentorial Sinuses; Drainage Pattern; Sphenoparietal Sinus; Cavernous Sinus