Vipul Gupta, Tanvir Rizvi, Ajay Garg, Shailesh B. Gaikwad, and N. K. Mishra
✓ The authors report the case of a 30-year-old man who presented with progressive neurological deficits due to a spinal arteriovenous malformation (AVM). There was sudden increase in his neurological deficits after diagnostic angiography was performed. Repeated magnetic resonance imaging and angiography revealed complete thrombosis of the malformation. Stenosis in the draining vein was the most probable cause of this postangiographic occlusion of the AVM. Contrast injection during angiography may have precipitated the thrombosis.
Aditya Gupta, M.Ch., Faiz U. Ahmad, Mehar C. Sharma, Ajay Garg, and Veer S. Mehta
✓Meningeal melanocytomas are uncommon intracranial tumors and their occurrence at the cerebellopontine angle (CPA) is extremely rare. The authors describe the case of a 58-year-old woman who presented with a left CPA tumor; on the basis of histopathological studies after resection, a diagnosis of meningeal melanocytoma was reached. The relevant literature is reviewed.
Shabari Girishan, Manjari Tripathi, Ajay Garg, Ramesh Doddamani, Jitin Bajaj, Bhargavi Ramanujam, and P. Sarat Chandra
The authors sought to analyze the residual connections formed by the temporal stem as a cause for seizure recurrence following endoscopic vertical interhemispheric hemispherotomy and to review and compare lateral approach (perisylvian) with vertical approach surgical techniques to highlight the anatomical factors responsible for residual connections.
This study was a retrospective analysis of patients who underwent endoscopic hemispherotomy for drug-resistant epilepsy. Postoperative MR images were analyzed. Specific attention was given to anatomical 3D-acquired thin-section T1 images to assess the extent of disconnection, which was confirmed with a diffusion tensor imaging sequence. Cadaver brain dissection was done to analyze the anatomical factors responsible for persistent connections.
Of 39 patients who underwent surgery, 80% (31/39) were seizure free (follow-up of 23.61 ± 8.25 months) following the first surgery. Thirty patients underwent postoperative MRI studies, which revealed persistent connections in 14 patients (11 temporal stem only; 3 temporal stem + amygdala + splenium). Eight of these 14 patients had persistent seizures. In 4 of these 8 patients, investigations revealed good concordance with the affected hemisphere, and repeat endoscopic disconnection of the residual connection was performed. Two of the 8 patients were lost to follow-up, and 2 had bihemispheric seizure onset. The 4 patients who underwent repeat endoscopic disconnection had seizure-free outcomes following the second surgery, increasing the good outcome total among all patients to 90% (35/39). Cadaveric brain dissection analysis revealed the anatomical factors responsible for the persistence of residual connections.
In endoscopic vertical approach interhemispheric hemispherotomy (and also vertical approach parasagittal hemispherotomy) the temporal stem, which lies deep and parallel to the plane of disconnection, is prone to be missed, which might lead to persistent or recurrent seizures. The recognition of this limitation can lead to improved seizure outcome. The amygdala and splenium are areas less commonly prone to be missed during surgery.
Mehar Chand Sharma, Chitra Sarkar, Deepali Jain, Vaishali Suri, Ajay Garg, and Sandeep Vaishya
✓The presence of müllerian-origin tissue in the lumbosacral region is extremely uncommon. The authors report two cases of müllerian-origin tissue in that region. In the first case a 33-year-old woman harbored a conus medullaris mass lesion. Spinal dysraphism, tethered cord syndrome (TCS), and diastematomyelia were also present. In the second case a 24-year-old woman presented with low-back pain and a conus medullaris lesion, which was a cause of the TCS. Pathological examination in both cases revealed a uterus-like structure with evidence of fresh and old hemorrhage. The rarity of this lesion and its association with diastematomyelia requires documentation.
Case report and review of the literature
Tanvir Rizvi, Ajay Garg, Nalini K. Mishra, Shailesh B. Gaikwad, and Vipul Gupta
✓ Spinal dural arteriovenous fistulas (DAVFs), the most common of spinal vascular malformations, are AVFs in the dura mater of the nerve root and/or adjacent spinal dura. These fistulas are most often solitary and are fed by a single radicular artery that primarily supplies the dura mater. Multiple spinal DAVFs are rarely reported in the literature. Those that have been documented have been synchronous in their presentation in that they were found during the same examination or were present at the initial examination but missed and only recognized at the second examination. The authors report the case of a patient with two spinal DAVFs occurring at different spinal levels at different points in time (metachronous).
Case report and review of the literature
Ajay Garg, Manish Chugh, Shailesh B. Gaikwad, Sarat P. Chandra, Vipul Gupta, Nalin K. Mishra, and Mehar Chand Sharma
✓ The authors report a case of a 13-year-old boy with juvenile pilocytic astrocytoma (JPA) presenting with subarachnoid hemorrhage (SAH). The patient experienced sudden onset of headache, vomiting, and loss of consciousness. Cranial computerized tomography scanning revealed blood within basal cisterns and the third ventricle. Angiography demonstrated normal cerebral vasculature and upward displacement of the bilateral A1 segments of the anterior cerebral artery. Magnetic resonance (MR) imaging revealed a chiasmatic/hypothalamic mass with evidence of hemorrhage. The mass was surgically decompressed. Histopathological examination showed evidence of JPA. In all cases of SAH in which there is blood around the third ventricle and a raised A1 segment on angiography, MR imaging should be performed. The presence of a normal sella turcica, as well as indistinct margins between the tumor and the opticochiasmatic apparatus should raise suspicion about the lesion.
Report of 2 cases
Aanchal Kakkar, Mehar C. Sharma, Nishant Goyal, Chitra Sarkar, Vaishali Suri, Ajay Garg, Shashank S. Kale, and Ashish Suri
Meningeal fibromas are rare intracranial tumors that mimic meningiomas radiologically as well as histologically. The authors report 2 cases of meningeal fibroma with detailed clinical, radiological, histopathological, and immunohistochemical features, and discuss the differential diagnosis of this entity. Knowledge of this rare tumor is essential for pathologists to be able distinguish it from more common meningeal tumors, especially in younger patients. This knowledge is also essential for neurosurgeons, as incomplete resection may lead to tumor recurrence, and such patients require close follow-up.
P. Sarat Chandra, Ramesh Doddamani, Shabari Girishan, Raghu Samala, Mohit Agrawal, Ajay Garg, Bhargavi Ramanujam, Madhavi Tripathi, Chandrashekar Bal, Ashima Nehra, and Manjari Tripathi
The authors present a new “bloodless” technique for minimally invasive robotic thermocoagulative hemispherotomy (ROTCH). Such a method is being described in the literature for the first time.
A robotic system was used to plan five sets of different trajectories: anterior disconnection, middle disconnection, posterior disconnection, corpus callosotomy, and temporal stem and amygdalar disconnection. A special technique, called the “X” technique, allowed planar disconnection. Registration was performed with surface landmarks (n = 5) and bone fiducials (n = 1). Coregistration with O-arm images was performed one or two times to confirm the trajectories (once for middle disconnection, and once for disconnection of the temporal stem and amygdala or body of the corpus callosum). Impedance measured before ablation allowed for minor adjustments. Radiofrequency ablation was performed at 75°C–80°C for 60 seconds. Surgical procedures were performed with multiple twist drills. After removal of the electrode, glue was used to prevent CSF leak, and a single stitch was applied. Follow-up CT and MRI were immediately performed.
The pathologies included Rasmussen's encephalitis (n = 2), hemispheric cortical dysplasia (n = 2), posttraumatic encephalomalacia (n = 1), and perinatal insult (n = 1). The mean ± SD (range) age was 6.7 ± 3.6 years (5 months to 10.2 years), and the right side was affected in 4 patients. The mean ± SD seizure frequency was 7.4 ± 5.6 seizures per day (1 patient had epilepsia partialis continua). The mean ± SD number of trajectories was 15.3 ± 2.5, and the mean ± SD number of lesions was 108 ± 25.8. The mean ± SD maximum numbers of trajectories and lesions required for middle disconnection were 7.1 ± 1.7 and 57.5 ± 18.4, respectively. All but 1 patient had class 1 outcomes according to the International League Against Epilepsy Outcome Scale at a mean ± SD (range) follow-up of 13.5 ± 1.6 (12–16) months; the remaining patient had a class 2 outcome. The estimated blood loss was < 5 ml for all patients. Complications included repeat surgery (after 2 weeks) for a “skip” area (n = 1) and a small temporal hematoma (n = 1), which resolved.
ROTCH seems to be a safe, feasible, and bloodless procedure, with a very low morbidity rate and promising outcomes.
P. Sarat Chandra, Heri Subianto, Jitin Bajaj, Shabari Girishan, Ramesh Doddamani, Bhargavi Ramanujam, Mahendra Singh Chouhan, Ajay Garg, Madhavi Tripathi, Chandrasekhar S. Bal, Chitra Sarkar, Rekha Dwivedi, Savita Sapra, and Manjari Tripathi
Endoscope-assisted hemispherotomy (EH) has emerged as a good alternative option for hemispheric pathologies with drug-resistant epilepsy.
This was a prospective observational study. Parameters measured included primary outcome measures (frequency, severity of seizures) and secondary outcomes (cognition, behavior, and quality of life). Blood loss, operating time, complications, and hospital stay were also taken into account. A comparison was made between the open hemispherotomy (OH) and endoscopic techniques performed by the senior author.
Of 59 cases (42 males), 27 underwent OH (8 periinsular, the rest vertical) and 32 received EH. The mean age was 8.65 ± 5.41 years (EH: 8.6 ± 5.3 years; OH: 8.6 ± 5.7 years). Seizure frequency per day was 7 ± 5.9 (EH: 7.3 ± 4.6; OH: 15.0 ± 6.2). Duration of disease (years since first episode) was 3.92 ± 1.24 years (EH: 5.2 ± 4.3; OH: 5.8 ± 4.5 years). Number of antiepileptic drugs per patient was 3.9 ± 1.2 (EH: 4.2 ± 1.2; OH: 3.8 ± 0.98). Values for the foregoing variables are expressed as the mean ± SD. Pathologies included the following: postinfarct encephalomalacia in 19 (EH: 11); Rasmussen’s syndrome in 14 (EH: 7); hemimegalencephaly in 12 (EH: 7); hemispheric cortical dysplasia in 7 (EH: 4); postencephalitis sequelae in 6 (EH: 2); and Sturge-Weber syndrome in 1 (EH: 1). The mean follow-up was 40.16 ± 17.3 months. Thirty-nine of 49 (79.6%) had favorable outcomes (International League Against Epilepsy class I and II): in EH the total was 19/23 (82.6%) and in OH it was 20/26 (76.9%). There was no difference in the primary outcome between EH and OH (p = 0.15). Significant improvement was seen in the behavioral/quality of life performance, but not in IQ scores in both EH and OH (p < 0.01, no intergroup difference). Blood loss (p = 0.02) and hospital stay (p = 0.049) were less in EH.
EH was as effective as the open procedure in terms of primary and secondary outcomes. It also resulted in less blood loss and a shorter postoperative hospital stay.