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Ashok Pillai, Georgie Mathew, Sivasankaran Nachimuthu and Sanjeevan Vasudevan Kalavampara

The management of ventriculoperitoneal (VP) shunt failure is a common problem in neurosurgical practice. On occasion, extraperitoneal sites for CSF diversion are required when shunting to the peritoneal cavity has failed after multiple attempts. The authors report a novel minimally invasive procedure allowing cannulation of the ureter for the purpose of ventriculo-ureteral (VU) shunting. Sixteen years prior to presentation, this 46-year-old woman had contracted tuberculous meningitis and had chronic hydrocephalus, with multiple distal shunt failures in recent months. A percutaneous nephrostomy was used to pass the distal catheter based on intraoperative retrograde pyelography. Following successful placement of the VU shunt, the patient's hydrocephalus stabilized and she returned to her regular functional status. The only long-term complication noted within 36 months of follow-up was a transient episode of electrolyte disturbance and dehydration associated with a diarrheal illness that responded to adequate hydration and salt supplementation. By its minimally invasive nature, this approach offers a reasonable extraperitoneal alternative after multiple distal shunt catheter failures have occurred.

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Ashok Pillai, Kariyattil Rajeev, Sushil Chandi and Muthukuttiparambil Unnikrishnan

✓ The authors report an intrinsic brainstem lesion that was diagnosed initially as a pontine cavernoma, which finally proved to be a choroid plexus papilloma. Choroid plexus papillomas are rare tumors of the central nervous system and are usually intraventricular in location. The occurrence of this tumor in an intraparenchymal location is extremely rare, and its occurrence within the brainstem is previously unreported. The authors also report a trial of chemotherapy with lomustine in the management of the residual tumor.

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Ajit Nambiar, Ashok Pillai, Chirag Parmar and Dilip Panikar

The authors present the case of an 11-year-old boy with an intraventricular chordoid meningioma, which is a rare presentation of prolonged fever of unknown origin due to a rare tumor in a rare location. The fever resolved after excision of the lesion. Subsequent imaging revealed recurrence at 1 year. After a repeat excision and fractionated radiotherapy, the patient has remained disease free 5 years after the first surgery. Very few cases of intraventricular chordoid meningioma have been reported to date. The pathological features and clinical course are described. A review of the literature describing management options for this tumor type, recently found to have a higher recurrence rate, is described herein.

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Ashok Pillai, Sajesh K. Menon, Satyendra Kumar, Kariyattil Rajeev, Anand Kumar and Dilip Panikar


Middle cerebral artery infarction often occurs at a younger age than other strokes and is associated with significant rates of mortality and morbidity. After a period of pessimism regarding decompressive hemicraniectomy in the management of acute stroke, the method has reemerged in the past decade. The present study was undertaken to assess the immediate and long-term outcome of this intervention and to help better define the selection criteria for surgery.


The authors conducted a nonrandomized prospective study using decompressive hemicraniectomy with duraplasty in patients at various stages of clinical deterioration due to a space-occupying middle cerebral artery infarct. Patients were assessed at 6 and 12 months postinfarction by using functional scales. Subjective reconsideration was assessed using a questionnaire.

Twenty-six patients were included in the study. The mean age was 48.4 ± 11.2 years, and the mean preoperative Glasgow Coma Scale score was 9.9 ± 3.2. The median time from ictus to surgery was 54 hours (range 13–288 hours). The rate of survival at 1 year postsurgery was 73%. Among survivors, 33.3% were independent (Barthel Index [BI] > 95) and 55.6% were partially dependent (BI 60–95) at 1 year postsurgery, with 72% attaining the ability to walk independently by 1 year postsurgery. No patient remained in a vegetative state. The 1-year BI score was inversely related to patient age (r = − 0.47, p = 0.048).


Survival after decompressive hemicraniectomy was better than previously reported using medical management alone. A vegetative state was avoided and functional independence was possible, especially in younger patients. Increasing age was a statistically significant predictor of disability and long-term functional dependence.

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Cumhur Kılınçer, Talip Asil, Ufuk Utku, Kemal Balcı and Mustafa Kemal Hamacıoglu