Giant cerebral tuberculoma is an uncommon but serious form of tuberculosis. We report two patients who had a single, large lesion on magnetic resonance imaging (MRI) of the brain. Both patients underwent neurosurgery for the excision of the mass lesion as neuroimaging findings were suggestive of a brain tumor. Tuberculoma was later diagnosed on histopathological examination. We want to highlight that cerebral tuberculomas can mimic malignant brain tumors, as the clinical, laboratory, and radiologic features of cerebral tuberculomas are nonspecific.

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Background The prevalence of low back pain with radiculopathy in general population varies from 9.9% to 25%, which can be due to bony narrowing of the lateral recess or due to prolapsed intervertebral disc. Transforaminal epidural injection of a mixture of long-acting anaesthetic (bupivacaine) and particulate steroids (depomedrol) has been a treatment modality in patients not responding to initial physiotherapy and neuropathic pain medications. Methods To analyze the effectiveness of transforaminal epidural steroid injection (TFESI) in the treatment of low back pain with radiculopathy, a retrospective case series evaluating the records of patients that received TFESI (1 mL 0.5% bupivacaine +1 ml/40 mg depomedrol) under C-arm guidance from January 2015 to December 2018 (3 years) at Upendra Devkota Memorial-National Institute of Neurological and Allied Sciences (UDM-NINAS), their lumbo-sacral MRI and the pre-procedure, 1-week and 3-month numeric pain rating scale, were analyzed. Successful treatment (reduction of pain scale by more than 50% of baseline at 3 months) in the patients with bony recess stenosis and those with prolapsed intervertebral disc was compared. Results Out of 67 patients that received TFESI, 35 (52.23%) could be followed up. The mean age was 55.8 ± 14.39 years and 51.3% were females. 68.57% had L5 and 20% had S1 radiculopathy. Bony recess stenosis was seen in the aged 40% and PIVD was the cause of radiculopathy in 60%. The median duration of radicular pain prior to intervention was 3 months. TFESI was effective as the mean numeric pain scale before injection was 8.97 ± 1.32 which reduced to 3.91 ± 3.23 (paired t test p value < 0.001) at 1 week post injection and 3.23 ± 3.34 (paired t test p value < 0.001) at 3 months post injection. Twenty-six of the 35 patients (75.29%) had more than 50% pain relief compared to baseline at 3 months and were satisfied. Nine patients continued to have pain; however, only one required a surgical intervention. The effectiveness of TFESI was not significantly different in different ages (Fisher’s exact test p value 0.182) and in different anatomic levels (Fisher’s exact test p value 0.241). Six out of eight patients with bony recess stenosis benefited as compared to 14 out of 19 patients with PIVD, though it was not statistically significant (Fischer’s exact test p value 0.688). There were no adverse events recorded. Conclusion TFESI is a safe and efficacious treatment modality in patients with radicular low back pain especially in aged patients in whom surgery under general anaesthesia is not free from risk.

The craniovertebral junction area refers to the osseous structures consisting of the occipital bone that surrounds the foramen magnum, the atlas, and the axis vertebrae. There is sparse literature about the morph metric measurement of craniovertebral junction region. We aim to derive a range of various measurements incraniovertebral junction area. This is a hospital based single center retrospective study conducted in our center among 100 consecutive computed tomography scans of craniovertebral junction obtained in adult patients who were admitted to our tertiary hospital for treatment of non-craniovertebraljunction conditions between 2017 and 2018.Various craniovertebral junction morphology parameters were measured and confidence interval at 95% were obtained the range at 2standard deviation. Among 100 patients studied, 51% of them were males while 49% were females. Mean age was 35.1±10.4 years with range from 15 to50 years. Computed tomography measurement of craniovertebral junction revealed meanders height of 30.8±2.5 mms, dento-clivaldistance was 5.9±1.6 mms and mean McRae’s distance of 34.2±2.49 mms. Similarly, anterioratlantodental interval was calculated to be1.83±0.47 mms and posterior atlantodentalinterval was 17.72±0.21 mms while Modified RW distance was 24.43±2.09 mms and Redlund Johnell distance was calculated to be 31.5±4.29mms. Normal morphometric measurements ofcraniovertebral junction can be useful for evaluating abnormalities of the craniovertebraljunction which can potentially improve the diagnostic criteria of most abnormalities.

Introduction: Preoperative differentiation of benign, atypical and malignant meningiomas would significantly help in surgical planning and treatment. The aim of this study is to look at radio- morphologic behavior of various histopathological types and grades of meningiomas and their diffusion characteristics.Methods: We performed an analytical cross-sectional study including all patients operated on for meningiomas at our hospital during January 2016 to July 2018. We studied 38 meningiomas in 38 patients aged 14 to 73 years old. All patients underwent MRI prior to surgery, including diffusion- weighted sequences, in a 1.5T scanner. Signal intensity in T2-weighted images, diffusion-weighted images (b=0, 90 and 1,000), and Apparent Diffusion Coefficient maps within the tumors and in the normal parietal white matter as a reference were evaluated. Results: There was female predilection with male:female ratio of 1:2.4. Most meningiomas were supratentorial with most common origin being parafalcine and convexity. Of the 38 meningiomas, 31 were WHO grade I, 6 were WHO grade II (apalstic) and one was WHO grade III (anaplastic). Similarly, tumors showing pial invasion, breached tumor-brain interface, no capsular enhancement and parenchyma invasion showed significantly low NADC. Mean ADC value was 0.722±7.7x10-3 mm2/s (normalized ADC 0.9±0.1) in the atypical group and 0.876±24.56x10-3 mm2/s (normalized ADC 1.11±0.31) in the typical group. No statistically significant differences of ADC/NADC were found between histologic subtypes. Two subtypes of typical meningiomas, metaplastic and angiomatous meningioma had the highest values in the ADC maps.Conclusions: MR morphology like pial invasion, breached tumors brain interface, parenchymal invasion can predict aggressiveness and atypical nature of meningiomas. Meningioma shows moderately restricted diffusion. The signal on the ADC map is associated with tumors cellularity and aggressiveness suggesting its usefulness for predicting the histological grade. Keywords: apparent diffusion coefficient; atypical; histopathology; meningioma; MR morphology.