R. Loch Macdonald
Thanga Thirupathi Rajan Vivakaran, Dwarakanath Srinivas, Girish Baburao Kulkarni and Sampath Somanna
Studies on the role of decompressive craniectomy for cerebral venous sinus thrombosis (CVST) in the literature are scanty. Randomized trials face a lot of drawbacks, including ethical issues. In this article the authors discuss their experience with this procedure for CVST and review the available literature.
This study was a retrospective analysis of all patients who underwent decompressive craniectomy for CVST between August 2006 and June 2008 at the National Institute of Mental Health and Neurosciences. The cases were evaluated for demographic and clinicoradiological features, operative findings, and outcome of surgery. Ethical clearance was obtained from the institutional ethics committee. The data for each patient were obtained from the database of the department. Follow-up data were obtained either through direct clinical evaluation or mailed self-report questionnaire. The Glasgow Outcome Scale (GOS) and the Rankin Disability Scale were used to assess the outcome.
A total of 34 patients (13 men and 21 women) were included; their mean age was 31.6 years, with a range from 18 to 65 years. In univariate analysis, the Glasgow Coma Scale (GCS) score prior to surgery and that in the immediate postoperative period had a statistically significant correlation with poor outcome. The GCS score immediately postoperatively was the only independent, significant predictor of poor outcome on multivariate analysis.
Decompressive craniectomy in a selected cohort of patients had a good outcome in a majority of the patients: 26 of 34 in this study had a GOS score of 4 or 5. In this series, which is the largest in the available literature, the authors review their experience and recommend usage of this procedure in selected patients.
Report of 3 cases
Umesh Srikantha, Indira Devi Bhagavatula, Satish Satyanarayana, Sampath Somanna and Bengaluru A. Chandramouli
✓Osteochondromas are the most common benign bone tumor. Although the metaphysial region of long bones is the usual site of these tumors, the vertebrae may be infrequently affected. The presentation may vary from typical compressive myelopathy to radiculopathy or radiculomyelopathy, depending on the site of involvement. The authors present 3 consecutive cases of cervical spine osteochondromas encountered over 3 years at their institution, each different in its site of involvement, presentation, and chosen treatment. The patient in Case 1 had the typical presentation and lesion site, and was treated with a conventional laminectomy. The patient in Case 2 presented with an extensive disease that required complex, staged surgery with spinal fusion and instrumentation. The patient in Case 3 presented with monoradiculopathy and had a facet joint osteochondroma that was successfully treated with a simple partial facetectomy, without laminectomy.
Raman Mohan Sharma, Nupur Pruthi, Arivazhagan Arimappamagan, Sampath Somanna, Bhagavathula Indira Devi and Paritosh Pandey
Hydrocephalus is one of the commonest complications of tubercular meningitis (TBM), and its incidence is increasing with the HIV epidemic. Literature evaluating the role of ventriculoperitoneal shunts in HIV-positive patients with TBM and their long-term prognosis is scarce.
Between June 2002 and October 2012, 30 HIV-positive patients with TBM and hydrocephalus underwent ventriculoperitoneal shunt placement. Thirty age-, sex-, and grade-matched HIV-negative patients with TBM and hydrocephalus were randomly selected as the control group. Outcome was analyzed at discharge (short-term outcome) and at follow-up (long-term outcome). Univariate and multivariate analyses were performed to look for predictors of outcome; p < 0.05 was considered significant.
There were no differences in the clinical, radiological, or biochemical parameters between the 2 groups. Short-term outcome was better in the HIV-negative group (76.7% improvement) than in the HIV-positive group (70%). However, the long-term outcome in HIV-positive patients was very poor (66.7% mortality and 76.2% poor outcome) compared with HIV-negative patients (30.8% mortality and 34.6% poor outcome). Seropositivity for HIV is an independent predictor of poor outcome both in univariate and multivariate analyses (p = 0.038). However, in contrast to previous reports, of 5 patients with TBM in good Palur grades among the HIV-positive patients, 4 (80%) had good outcome following shunt placement.
The authors recommend that shunt treatment should not be performed in HIV-positive patients in poor Palur grade with hydrocephalus. A trial of external ventricular drainage should be undertaken in such patients, and shunt treatment should be performed only if there is any improvement. However, HIV-positive patients in good Palur grades should undergo VP shunt placement, as these patients have better outcomes than previously reported.
Umesh Srikantha, Jagadeesh V. Morab, Savitr Sastry, Rojin Abraham, Anandh Balasubramaniam, Sampath Somanna, Indira Devi, Chandramouli A. Bangalore and Paritosh Pandey
Hydrocephalus is the most common complication of tubercular meningitis (TBM). Relieving hydrocephalus by ventriculoperitoneal (VP) shunt placement has been considered beneficial in patients in Palur Grade II or III. The role of VP shunt placement in those of Grade IV is controversial and the general tendency is to avoid its use. Some authors have suggested that patients in Grade IV should receive a shunt only if their condition improves with a trial placement of an external ventricular drain (EVD). In the present study, the authors assessed the outcome of VP shunt placement in patients in Grade IV TBM with hydrocephalus to examine the factors predicting outcome and to determine whether a trial with an EVD is absolutely necessary prior to shunt placement.
Ninety-five consecutive cases of TBM with hydrocephalus in which the patients underwent VP shunt placement were retrospectively analyzed, and direct VP shunts were placed whenever possible. An EVD was placed first only in the presence of deranged blood parameters. Outcomes were assessed both in the short and long term.
The mean patient age was 17.5 years (range 1–55 years). Fifty-two patients underwent direct VP shunt placement, and the remaining 43 received EVDs first. Overall, 33 and 45% of patients had favorable short- and long-term outcomes, respectively. Age older than 3 years and duration of altered sensorium ≤ 3 days were predictive of a favorable short-term outcome. Glasgow Coma Scale score at presentation was predictive of long-term outcome. Of the patients who did not improve with placement of an EVD prior to VP shunt insertion, 24 and 18% had favorable short- and long-term outcomes, respectively; this was not significantly different from the outcome in the patients who underwent direct VP shunt placement.
Direct VP shunt placement is an effective option in patients with Grade IV TBM with hydrocephalus. Age and duration of altered sensorium are predictive of short-term outcome, while Glasgow Coma Scale score at presentation predicts long-term outcome. Ventriculoperitoneal shunts should be considered even in patients who do not improve with an EVD.
Madhugiri S. Venkatesh, Paritosh Pandey, B. Indira Devi, Kiran Khanapure, Sathyanarayana Satish, Somanna Sampath, Bangalore A. Chandramouli and Kolluri V. R. Sastry
Pediatric cases of infratentorial subdural empyema (SDE) are both rare and associated with high rates of morbidity and mortality. The goal of this study was to report patient characteristics, treatment, and outcome in an exclusively pediatric series of SDE cases.
A series of 14 pediatric cases of infratentorial SDE wasretrospectively analyzed. All patients were treated between 1994 and 2004. Sixty-four percent of the patients were boys; the majority of cases occurred during the summer months. Clinical features included headache, fever, vomiting, meningism, and otorrhea. Cerebellar signs were found only in 21% of patients. In 85.7% of the cases, the patients presented with a depressed level of consciousness (Glasgow Coma Scale Scores 11–15). In 79.6%, pus collection was seen over the cerebellar convexity; interhemispheric and tentorial collections were also observed in some cases. Hydrocephalus was present in 92.9% of patients. Five patients required external ventricular drainage during surgery or postoperatively. Shunt placement was required in 21% of cases.
All patients were treated with antibiotic therapy and surgery (bur holes in 21% of the cases, craniectomy in 79%). Pus cultures demonstrated microbial infection in 71.4%, and polymicrobial infection in 21%. Four patients required repeated surgery for reaccumulation of pus. Minor postoperative complications developed in three patients. All 14 patients survived. At follow up, the Glasgow Outcome Scale scores were 4 or 5 in all cases.
Early diagnosis and prompt surgical treatment are crucial in cases of SDE. With appropriate surgery, antibiotic therapy, and management of hydrocephalus, good outcome can be expected.
Ajit Mishra, Andiperumal Raj Prabhuraj, Dhaval P. Shukla, Bevinahalli N. Nandeesh, Nagarathna Chandrashekar, Arvinda Ramalingaiah, Arimappamagan Arivazhagan, Dhananjaya Ishwar Bhat, Sampath Somanna and Bhagavatula Indira Devi
Intracranial fungal granuloma (IFG) remains an uncommon entity. The authors report a single-institute study of 90 cases of IFG, which is the largest study until now.
In this retrospective study, all cases of IFG surgically treated in the years 2001–2018 were included. Data were obtained from the medical records and the pathology, microbiology, and radiology departments. All relevant clinical data, imaging characteristics, surgical procedure performed, perioperative findings, and follow-up data were recorded from the case files. Telephonic follow-up was also performed for a few patients to find out their current status.
A total of 90 cases consisting of 64 males (71.1%) and 26 (28.9%) females were evaluated. The mean patient age was 40.2 years (range 1–79 years). Headache (54 patients) was the most common presenting complaint, followed by visual symptoms (35 patients), fever (21 patients), and others such as limb weakness (13 patients) or seizure (9 patients). Cranial nerve involvement was the most common sign (47 patients), followed by motor deficit (22 patients) and papilledema (7 patients). The mean duration of symptoms before presentation was 6.4 months (range 0.06–48 months). Thirty patients (33.3%) had predisposing factors like diabetes mellitus, tuberculosis, or other immunocompromised status. A pure intracranial location of the IFG was seen in 49 cases (54.4%), whereas rhinocerebral or paranasal sinus involvement was seen in 41 cases (45.6%). Open surgery, that is, craniotomy and decompression, was performed in 55 cases, endoscopic biopsy was done in 30 cases, and stereotactic biopsy was performed in 5 cases. Aspergilloma (43 patients) was the most common fungal mass, followed by zygomycosis (13 patients), chromomycosis (9 patients), cryptococcoma (7 patients), mucormycosis (5 patients), and candida infection (1 patient). In 12 cases, the exact fungal phenotype could not be identified. Follow-up was available for 69/90 patients (76.7%). The mean duration of the follow-up was 37.97 months (range 3–144 months). The mortality rate was 52.2% (36/69 patients) among the patients with available follow-up.
A high index of suspicion for IFG should exist for patients with an immunocompromised status and diabetic patients with rhinocerebral mass lesions. Early diagnosis, aggressive surgical decompression, and a course of promptly initiated antifungal therapy are associated with a better prognosis.