BackgroundAcute hydrocephalus can cause neurological deterioration after aneurysmal subarachnoid hemorrhage (aSAH). Predicting which patient would require shunting is challenging.MethodsThis prospective study was conducted upon twenty patients who suffered acute hydrocephalus due to subarachnoid hemorrhage of ruptured aneurysms. Surgical or non-surgical management of hydrocephalus was conducted. Glasgow Coma scale (GCS) was assessed, and hydrocephalus was graded by bicaudate index. Fisher grade was determined from CT scan. Aneurysm site was determined by conventional or CT angiography. Either surgical clipping or endovascular coiling of aneurysms was performed.ResultsInitially, 3 (15%) patients had emergency CSF diversion on admission due to poor GCS on arrival. Initially, the remaining 17 patients were managed conservatively. Five patients did not require any intervention. Twelve patients had external ventricular drainage placement, 4 were weaned, and 8 failed weaning. High bicaudate index (> 0.2) correlated with shunting. Aneurysm site correlated well with shunting (ACoA or PCoA).ConclusionsPatients with fair GCS can be managed conservatively. Any deterioration warrants shifting to CSF diversion. Higher bicaudate index will usually need CSF diversion. The value of Fisher carries no significant value. Aneurysm location (ACoA or PCoA) correlates with an increased incidence of ventriculoperitoneal shunt placement.

BackgroundMeningeal melanocytoma is considered a rare lesion arising from leptomeningeal melanocytes. Nearly two thirds of meningeal melanocytomas were reported in the intracranial compartment and the remaining one third in the spine. Spinal melanocytomas can be extradural or intradural, with extradural variant being more common, and the majority of cases have been single reports.MethodsA 5-year-old male presented with a 4-month history of non-radiating low back pain persistent at rest, with otherwise non-remarkable medical history. The patient was neurologically intact with no deficits. Preoperatively, routine laboratory investigations were non-remarkable. MRI imaging was done and showed a lesion at the level of T11 to L4, hyperintense on T1 and hypointense on T2 with homogenous contrast enhancement. Intraoperatively, the lesion was hemorrhagic, brownish, and rubbery in consistency attached to the ventral dura. Microscopic picture revealed dense cytoplasmic brown melanin pigments, with no significant mitoses or nuclear atypia. What is unique about our case is the age of the patient (5 years).ResultsTo the best of our knowledge, after reviewing the literature, this is the youngest case to be reported.ConclusionsSMM is an extremely rare tumor with a benign course. Complete surgical excision should be attempted. Age of presentation may be as young as in our case and the diagnosis of such a tumor should never be excluded in this early age group with persistent low back ache.

Background: Spinal infections can be challenging in their management and include spondylitis, epidural abscess, and spondylodiscitis. Usual treatment is conservative through antimicrobials or surgery to decompress neural tissue, debride all infected tissues, and fix if needed. We propose the concept of surgery without formal debridement aiming at neural protection. Methods: The study was performed at two tertiary centers on 25 patients with clinical findings. One patient was treated conservatively and the rest surgically by laminectomy and fixation if needed. Evacuation of fluid pus was performed. In the cervical and the thoracic region, if the granulation tissue was anterior to the cord, only decompression by laminectomy was done. Results: Low back pain was present in 22 cases (88%), 16 cases (64%) had lower limb pain, and 12 cases (48%) had weakness. The level of spinal infection was lumbar in 15 cases (60%), thoracic in 9 cases (36%) cases, and cervical in 1 case (4%). The type of infection was epidural abscess in 20 cases (80%), discitis in 16 cases (64%), and vertebral osteomyelitis in 12 cases (48%). Laminectomy was performed in 20 cases (80%) and fixation in 17 cases (68%). The symptoms improved in all cases. On follow-up, the lesion was reduced in 14 patients (56%) and disappeared in 11 cases (44%). One case required ventriculoperitoneal shunt placement due to postinfectious hydrocephalus. Conclusion: Dealing with spinal infections surgically through decompression or fixation with minimal debridement of infected tissue appears to be a safe and effective method of management.

No abstract

Background: Treatment of odontoid fractures with odontoid screws is an established method for fusion. However, it is facilitated by using advanced equipment in the operating theatre not always available as in developing countries. Objectives: In this study we aim to outline the important key points for successful placement of odontoid screw in the absence of advanced tools, e.g. navigation or O-arm. Materials and methods: Fifteen patients suffering from type II odontoid fractures were managed with single odontoid screw. Reduction of the fractures was achieved. A simple instrument set was used with the help of a single plane image intensifier. Longitudinal incision was used in 4 cases, and transverse incision was used in the remaining eleven cases. Anatomical identification of the midline helped to mark the entry point. The entry point used was millimetres below the anteroinferior edge of the axis vertebra. A short-headed screw was used. Results: Road traffic accident was the only mechanism of trauma reported in our study. All of the patients were neurologically intact. All of the patients remained neurologically intact after the procedure. There were no instances of wrong trajectory of the screw in our study. During follow-up, we found good union of all the fractures. Only 2 cases suffered from mild dysphagia. Conclusion: Fixation of odontoid fractures by anterior odontoid screws appears to be a safe and feasible procedure even in underequipped theatres. Anatomical knowledge helps in determining midline. Various modifications can help in overcoming shortcomings.