Intracranial tuberculomas: Diagnosis and management

Summary Experience with fifteen consecutive cases of intracranial tuberculomas, treated between 1981 and 1986, is summarized. Histological confirmation was obtained in twelve patients, and acid fast bacilli (AFB) were found in and cultured from the excised lesions and biopsy specimens in nine patients. Difficulties in diagnosis are discussed. A plan of management combining the operative treatment and medical therapy of the tuberculomas is outlined. The value of computerized tomography in the diagnosis and management of these patients is emphasized.     

Haemorrhage in intradiploic haemangioma mimicking extradural haematoma

Summary Traumatic haemorrhage in a previously occult intradiploic haemangioma in an elderly lady resulted in clinical and computer tomographic (CT) appearances mimicking an extradural haematoma. Literature relevant to this rare situation is briefly discussed.     

Intramedullary ossified cavernous angioma of the spinal cord: case report

A case of a heavily ossified cavernous angioma of the spinal cord along with its histological features and surgical implications is reported. The unusually dense calcification and even bone formation along with the unique eggshell-like cyst formation posed problems in diagnosis and surgical excision. This calcified vascular lesion was treated by subtotal excision.     

Atypical forms of spinal tuberculosis

Summary Twenty-three patients with atypical forms of spinal tuberculosis treated between 1975 and 1985, are described.All presented with signs and symptoms of compression of the spinal cord or cauda equina, ranging from paraesthesiae and increasing weakness of extremities to paraplegia and loss of sphincter control. None of them showed visible or palpable spinal deformity nor the typical radiographic appearance of destruction of the intervertebral disc and the two adjoining vertebral bodies. These atypical forms constituted about 12 percent of all the cases of spinal tuberculosis seen (a total of 190 cases); and fell into three well-defined groups: those with the involvement of neural arch only; those with the inolvement of a single vertebral body; and, those without bony involvement. The correct surgical approach in these groups was found to be different: spinal cord compression caused by the tuberculous disease of the neural arch was best treated by laminectomy; whereas single vertebral body disease required an anterior or anterolateral approach. Spinal computerized tomography was helpful in defining the extent of disease and planning the surgical approach. Histological confirmation of tuberculosis was obtained in all the cases and acid fast bacilli (A.F.B.) were found in, and cultured from, the biopsy specimens of 18 cases.     

Primary midline cranial vault lymphoma simulating a parasagittal meningioma: The role of angiography in preoperative diagnosis

Primary non-Hodgkin's lymphoma (NHL) of the skull with extra- and intracranial extension without systemic or skeletal manifestation in a non-immunocompromised patient is extremely rare. Up to date, only nine such cases have been reported in the literature and in none was the lesion located in the midline. The authors report a unique case of a primary NHL involving the midline of the cranium. The lesion presented as a slowly growing scalp swelling mimicking a parasagittal meningioma. The angiographic findings of mild vascularity in the periphery of the tumor and downward displacement of a patent superior sagittal sinus indicated that the lesion was unlikely to be a meningioma. Neurosurgeons must maintain a broad differential diagnosis in any patient with a scalp mass eroding through the skull and associated neurological symptoms or signs. An intraoperative frozen section is recommended since the identification of a lymphoma is likely to influence the neurosurgeon's decision about the extent of the surgical excision.     

Growing skull fractures: Surgical management of difficult and atypical cases

Summary The authors treated and followed-up 11 patients with growing skull fractures during the last 10 years. Two atypical forms of these fractures, characterized by difficulties in surgical repair or failure of conventional procedure, were identified. Five patients required unconventional procedures to effect a cure. Thus, three required shunt surgery (ventriculoperitoneal, n = 2 and cystoperitoneal, n = 1) and two recurrent cases had a modified surgical procedure. This unique and useful method of repairing this defect is described as well.     

Cranial and epidural mycetoma caused by streptomyces somaliensis

Summary The authors report a rare case of cranial and intracranial mycetoma which presented with occipital sinuses, extensive involvement of skull vault and base, an extradural granuloma and intracranial hypertension. Radiological appearances are reviewed. The computerized tomography findings are the first of their kind for this condition. The diagnosis and treatment of this disease are discussed.     

Modified coronal computerized tomographic cuts for transsphenoidal surgery. Technical note

Computerized tomographic (CT) cuts passing through the anterior nasal spine and the most prominent part of the sellar floor (spino-sellar or SS cuts) were found to be use-ful in minimizing the chances of anatomical disorientation during the transsphenoidal microsurgical approach as well as in preoperative planning and selection of the length and choice of the instruments to be used. Routine preoperative SS cuts of CT scan are advised.     

Cranial and intracranial aspergillosis of sino-nasal origin

Summary This paper is an attempt at defining the most efficacious surgical and antifungal therapy for invasive cranial and intracranial aspergillosis, and is based on experience with nine non-immuno-compromised patients treated and followed-up by the authors between 1983 and 1994; as well as on the summary of previously reported cases and advances in therapy of this condition. Depending on the degree of aspergillar involvement of the cranial base and intracranial structures, a classification, with implications for treatment and prognosis, is also proposed.Two patients had extracranial skull base erosion; whereas relentlessly progressive granulomas, mimicking malignancy, invaded the skull base and intracranial contents in seven cases. Of these seven patients with cranial and intracranial invasion, two died of acute intracranial haemorrhage due to fungal invasion of cerebral blood vessels. In two patients, complete surgical eradication of the disease proved impossible due to cavernous sinus involvement, while residual aspergillomas are still present in orbit and paranasal sinuses (PNS) in a further two patients in spite of multiple surgical procedures and prolonged antifungal chemotherapy (AFC). What appears to be a cure has been effected in one patient only. Multiple therapeutic strategies were used. Biopsy plus systemic AFC was ineffective, surgical drainage and debridement plus systemic AFC resulted in long-term survivals but no cure. Radical surgery in conjunction with systemic and local (intracavitary) AFC should be considered to improve an otherwise poor prognosis.