Sibhi Ganapathy

The concepts of consciousness, coma and wakefulness have fascinated man from the ages. The explanation and thereby, understanding of different states of altered consciousness vary from mystic, spiritual to anatomic and scientific. The advent of experimental neurology and anatomy gradually expanded the scientific horizons of man allowing observations and measurements to be made and interpreted.  Keywords: Coma, Conciousness.

A 73-year-old male patient suffered from recurrent strokes over 2 years. An angiogram revealed a giant cervical ICA aneurysm located in the retromandibular region with a tortuous loop of redundant artery anterior to it. He was taken up for surgery where the aneurysm was resected and the free ends anastomosed under shunt cover. The patient recovered well and was discharged without deficits. Another 70-year-old lady presented with a swelling in the retro mandibular region of the neck associated with fainting episodes every time she opened her mouth wide or chewed. Angiographic studies showed a giant retro mandibular ICA aneurysm, which was treated with an EC-IC bypass with ligation of the aneurysmal sac. The patient was discharged without deficits and has hence been living normally. Cervical aneurysms are rare and challenging modality to treat for the vascular neurosurgeon. These reports highlight the variability of presentation and the choice of modalities available for treatment. Selection of the appropriate modality can be challenging. Hence, we suggest a treatment algorithm for diagnosing as well as treating the disease successfully. Keywords: Giant, Cervical aneurysm, Coiling, Surgery.

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. Keywords: Metastatic, Renal cell carcinoma, Intradural, Extramedullary, Cauda equina.

Carotid webs are an evolving diagnosis made more often now, than before the advent of angiography. The webs are defined as a small intimal outgrowth that forms an obstruction to the streamlined flow of blood in the carotid artery. Angiographically they are defined as a filling defect seen in the bulb of the ICA just after the bifurcation of the ICA. These webs by virtue of their disruption of the laminar flow of blood give rise to slow eddy currents that result in thrombosis and thrombo-embolism. We present a patient who complained of recurrent strokes who was investigated extensively elsewhere without result. An angiogram of the carotid circulation showed a carotid intimal web at the posteromedial aspect of the ICA bulb, just distal to the common carotid artery bifurcation. The web was treated with an endovascular stent placement, which collapsed the web and its pocket of eddy currents completely thereby eliminating the danger posed by it. The report highlights the difficult nature of diagnosis while looking at prevalence and incidence of webs in the carotid system. The therapeutic options as well as prognosis in the short and long term are also addressed in the accompanying literature review. Keywords: Carotid webs, Stroke, Self expanding stent.