Spontaneous intracranial hypotension (SIH) is rare. It presents as intractable posture headache and is identified by radiological findings. It is confirmed by cerebrospinal fluid (CSF) manometry and myelography, and treatment is carried out with the help of epidural blood patch (EBP) therapy. SIH presenting with spontaneous bilateral recurrent subdural bleeds is uncommon. The cause being a high-spinal CSF leak is even more uncommon! Our patient had recurrent bilateral spontaneous chronic subdural hematomas. Myelographic examination of the spine showed a C1–C2 level leak of CSF. He was taken up for open microsurgery, and the leak was identified and closed with fibrin glue. The patient however deteriorated the next day. An EBP was applied in the lumbar region to cover the myelogram lumbar puncture site. We present a review of literature and an algorithm to detect the elusive CSF leak and effect definitive treatment, either open or EBP, to treat the source of the problem.
DESCRIPTIONThe ventriculoperitoneal shunt has been the mainstay for definitive treatment of hydrocephalus since time immemorial. As such, several case reports describing the complications of this procedure have been documented in the literature over the past few decades. The spectrum ranges from ventricular catheter dislodgement to abdominal catheter end perforating the stomach and causing intussusception; several case illustrations have depicted the possible aftermath of this blind procedure. After the advent of neuronavigation and planning procedures on CT scans, the complication rates have significantly reduced.Shunt malfunction, secondary to migration of the abdominal end, remains as one of the most common complications following ventriculoperitoneal shunting.1 Large bowel perforation is a rare complication with an incidence of 0.1-0.7%.2 In rare instances, there have been cases of herniation of the peritoneum along with the distal end of the catheter through a lax posterior rectus sheath.3 The unprecedented cases we describe, the first of a child and the other of an elderly woman, mandate a separate mention in the literature. We present our institutional experience, treatment dilemma, surgical management and outcomes in both the patients.Case 1: A 1½-year-old boy presented with intermittent appearance of the distal end of a ventriculoperitoneal shunt tube at the anus, while attempting to pass stools. The mother said that the child had been treated for obstructive hydrocephalus with a medium pressure Chhabra shunt, 9 months prior. On neurological examination, the child was active and alert; he had acquired appropriate milestones for his age and had no meningeal signs. The shunt chamber seemed to be functioning well. He was investigated with a shunt series X-ray, which revealed the distal end of the shunt tube traversing the entire lumen of the large intestine and ending in the sigmoid colon ( figure 1A). A CT scan (brain CT) was ordered, which showed a significant
There are only 8 reported cases of intradural extramedullary epidermoids without associated trauma or spinal dysraphism so far. Thus, this occurrence along with its successful surgical excision present a unique representation of spinal epidermoids and their natural history, along with a review of relevant literature.
Intradural extramedullary spinal metastasis is rare, representing 6% of all spinal metastasis. Indeed, intradural metastasis from a Renal Cell Carcinoma to the cauda equina is extremely rare with only 11 case reports present in the past. We present a patient with Cauda equina syndrome with an intradural extramedullary lesion causing compression of the nerve roots. He was subjected to a surgical decompression of the cauda equina with excision of the mass. The pathological examination displayed metastatic clear cell RCC with infiltration of the cauda equina. Thus, metastatic tumors constitute an important differential diagnosis for all lesions of the spine irrespective of level or location.
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