A red herring CVA with unexpected outcome: illustrative case

BACKGROUND Disruptions to the integrity of the inner table and trabeculae of the calvaria are rare phenomena. Increasingly rare is the phenomenon of herniation of brain parenchyma through the defects in the skull causing neurological deficit. Surgical intervention is commonly performed but is fraught with risk of brain tissue loss. OBSERVATIONS The authors present a case of a 78-year-old White male presenting with strokelike symptoms who was found to have an intradiploic encephalocele that was successfully treated with surgical intervention and neuroplastic reconstruction of the anatomical deficit. The patient had a marked recovery and had near-complete resolution of symptoms. LESSONS This notably rare phenomenon resolved with neurosurgical intervention, sparing the parenchyma, and provided the patient with perceivably normal contour of the head using a collaborative approach with neuroplastic intervention.

The efficacy of cystoperitoneal shunting for the surgical management of intracranial arachnoid cysts in the elderly: A systematic review of the literature

Background: Intracranial arachnoid cysts (AC) are benign, cerebrospinal fluid filled spaces within the arachnoid layer of the meninges. Neurosurgical intervention in children and young adults has been extensively studied, but the optimal strategy in the elderly remains unclear. Therefore, we performed a single center retrospective study combined with a systematic review of the literature to compare cystoperitoneal (CP) shunting with other surgical approaches in the elderly cohort. Methods: Retrospective neurosurgical database search between January 2005 and December 2018, and systematic review of the literature using PRISMA guidelines were performed. Inclusion criteria: Age 60 years or older, radiological diagnosis of intracranial AC, neurosurgical intervention, and neuroradiological (NOG score)/clinical outcome (COG score). Data from both sources were pooled and statistically analyzed. Results: Our literature search yielded 12 studies (34 patients), which were pooled with our institutional data (13 patients). CP shunts (7 patients; 15%), cyst fenestration (28 patients; 60%) and cyst marsupialisation/resection (10 patients; 21%) were the commonest approaches. Average duration of follow-up was 23.6, 26.9, and 9.5 months for each approach, respectively. There was no statistically significant association between choice of surgical intervention and NOG score (P = 0.417), COG score (P = 0.601), or complication rate (P = 0.955). However, CP shunting had the lowest complication rate, with only one patient developing chronic subdural haematoma. Conclusion: CP shunting is a safe and effective surgical treatment strategy for ACs in the elderly. It has similar clinical and radiological outcomes but superior risk profile when compared with other approaches. We advocate CP shunting as first line neurosurgical intervention for the management of intracranial ACs in the elderly.

Electrical Injuries and Neurosurgery: A Case Report and Review of Literature

Introduction Electrical injuries account for 5 to 27% of admissions to burn units. The nervous system is affected in as much as 21% of nervous injuries, with reported mortality. Case Report The authors report a case of a patient presenting to the neurosurgical service with a traumatic brain injury (TBI) caused due to an electrical burn. Available data was reviewed through a PubMed search of literature, with special attention to the nature of presentation, classification of such injuries, the pathophysiology of the events that arise, complications to be expected, and the guidelines for management. Conclusion It is possible for electrical injuries to cause TBIs requiring neurosurgical intervention.

Treatment of an Elusive Symptomatic Sinus Pericranii: Case Report and Review of the Literature

Sinus pericranii (SP) are abnormal vascular connections between extracranial scalp venous channels and intracranial dural sinuses. This vascular abnormality rarely results in significant sequelae, but in select cases, it can be symptomatic. We describe the case of a 7-year-old girl with an SP who experienced intermittent visual, motor, and sensory symptoms not previously described in the literature. Her symptoms resolved after surgical treatment of the SP. We propose a mechanism for her symptoms and the rationale for the role of neurosurgical intervention along with a review of the literature.

Clinical characteristics and outcome of hydrocephalus in neurosarcoidosis: a retrospective cohort study and review of the literature

Hydrocephalus is reported in approximately one-tenth of neurosarcoidosis patients. However, data on clinical characteristics and outcome are lacking. In this retrospective study, we present 11 patients with neurosarcoidosis and hydrocephalus on neuroimaging. Median age was 52 years and seven were female (64%). Presenting symptoms consisted of headache in 8 out of 11 (73%), vertigo in 5 (46%), gait abnormalities in 4 (36%), diplopia in 2 (18%) and decreased visual acuity in 1 (9%). Cranial imaging showed obstructive hydrocephalus in 10 (91%) and non-obstructive hydrocephalus in 1 (9%) out of 11, obstruction occurred at the level of the fourth ventricle in 6 out of 10 (60%). Treatment consisted of glucocorticoids in all the patients with additional methotrexate or azathioprine in 6 (55%) and infliximab in 1 (9%) patient. Neurosurgical intervention was performed in 10 out of 11 (91%) patients. Treatment led to remission, improvement or stabilization of disease in 9 out of 10 (90%) of patients. One patient died due to cerebral herniation despite neurosurgical decompression and CSF shunting. Median modified Rankin scale score at last follow-up was 2 (range 0–6). A systematic review and meta-analysis of studies on hydrocephalus due to neurosarcoidosis identified 36 patients that compared to our patients had a lower median age at onset and a higher mortality. Acute obstructive hydrocephalus due to neurosarcoidosis is a potentially fatal medical emergency requiring neurosurgical intervention and initiation of immunosuppressive therapy. If patients survive the initial phase, the outcome is generally favorable.

Congenital nephrogenic diabetes insipidus and the trauma injured brain: A case report

Diabetes insipidus is commonly attributed as post-surgical complication of neurosurgical procedures. The case presented here describes the antithesis, where a young man with nephrogenic diabetes insipidus requires emergency neurosurgical intervention. Complex treatment goals and fluid strategies are discussed. Keywords: nephrogenic diabetes insipidus; fluid management; traumatic brain Injury.

Analysing the reasons for rejection of neurosurgery intervention in patients with Parkinson’s disease referred to an extrapyramidal movement disorders clinic

We present findings of a 10-year retrospective study, analysing the reasons for rejection of neurosurgical intervention (deep brain stimulation or DBS) in patients with Parkinsons disease, who were referred to an extrapyramidal movement disorders clinic and then to a neurosurgery centre. It was found that after screening, 78.6% of patients referred as candidates for neurosurgical treatment to an extrapyramidal movement disorders clinic were rejected, while 21.4% of patients were referred to a neurosurgery centre, where 12% underwent surgery. The main reasons for rejecting potential DBS candidates were: early referral, inadequate pharmacotherapy, levodopa-resistant symptoms, atypical/secondary Parkinsonism, cognitive reasons, psychological reasons, comorbidity, abnormal MRI, poor response to levodopa medication and declined surgery. Furthermore, the number of self-referrals decreased, the number of patients referred by neurologists increased, the number of rejections of unsuitable DBS candidates decreased, and the number of suitable candidates referred to the extrapyramidal centre increased during the time period of 10 years. In addition, the number of patients who were referred to the neurosurgery centre and underwent surgery there increased, which suggests greater awareness of the selection criteria among doctors, as well increased knowledge and experience among neurologists in both primary healthcare and specialized centres.