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P. Sarat Chandra and Mohit Agarwal

The author has described his own technique of DCER (distraction, compression, extension, and reduction) to reduce and realign the deformity and relieve spinal compression (indicated in congenital anomalies with occipitalized C1 arch). In addition, he developed special C1–2 spacers and a universal reducer. Here, a 30-year-old male with severe BI (20 mm, above the clivus) with AAD underwent the technique of spacer placement (distraction) followed by cable reduction (leading to compression and extension at the occiput–C1–C2 region). Another short example is presented where an 8-year-old boy (severe BI, AAD with posterior fossa dermoid) underwent additional correction—C2 forward translation and excision of the dermoid.

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P. Sarat Chandra and Manjari Tripathi

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Rajinder Kumar, Sarat P. Chandra and Bhawani Shanker Sharma

The management of intradiploic CSF collection is controversial. Although it is a benign lesion, even then delay in diagnosis and treatment may lead to significant morbidity. The authors report a very rare case of giant posttraumatic intradiploic pseudomeningocele involving the occipital bone, occipital condyles, and clivus. The pathogenesis and management of intradiploic CSF collection are discussed.

This 16-year-old boy presented with a history of enlarging swelling in the suboccipital region associated with headache, lower cranial nerve palsy, and features of high cervical compressive myelopathy. Investigations revealed a giant intradiploic lesion involving the occipital bone, condyles, and clivus associated with secondary basilar invagination, hydrocephalus, and syringomyelia. Intrathecal contrast administration did not reveal communication of intradiploic space with the subarachnoid space. A large occipital craniotomy was performed. A linear fracture and dural defect in the midline was identified, which was closed with fascial graft after removing the inner table of the skull. Cranioplasty was performed using the expanded calvarial bone. Ventriculoperitoneal shunt insertion was performed for hydrocephalus, and the patient improved remarkably.

Posttraumatic intradiploic CSF collection, although a benign condition, may present with severe complications if treatment is delayed. Early diagnosis and treatment is essential. The authors suggest that this condition should be treated early, as for growing skull fractures.

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Sandeep Sood, Neena I. Marupudi and Steven D. Ham

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Pankaj K. Singh, Mohit Agrawal, Dattaraj Sawarkar, Amandeep Kumar, Satish Verma, Ramesh Doddamani, P. Sarat Chandra and Shashank S. Kale

Hangman’s fracture, also known as traumatic spondylolisthesis of the axis, causes widening of the neural canal and thus a low rate of neurological deficits. This low rate is one of the reasons it is neglected and patients present with late neurological deficits. In an effort to preserve motion at the C1–2 joint, the authors devised a new technique of bilateral C2 pedicle reconstruction. They describe the first two cases in the literature of an old hangman’s fracture with resorbed C2 pedicles due to chronic fracture, in which bilateral C2 pedicles were reconstructed. One of the two cases (case 2) is the first reported case of severe C2–3 spondyloptosis with C2 displaced up to the level of C4. Case 1 had a follow up of 21 months, while case 2 had a follow up of 12 months. Both patients experienced neurological improvement with evidence of fusion and artificial pedicle formation at last follow-up. Bilateral C2 pedicle reconstruction is a feasible technique that can be used with a good outcome in select patients.

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P. Sarat Chandra and Manjari Tripathi

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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.

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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.