Pneumocephalus following Ventriculoperitoneal (VP) shunt is an exceptionally rare entity. We report such event after an attempt of ventricular puncture (ventriculostomy) for VP shunt and then discuss the management of the same. The dry tap can lead to multiple attempts for ventriculostomy with added risk of complications. It can add dilemma as to what the subsequent management would be.There is also increased risk of tension pneumocephalus, seizures and shunt failure due to blockage by air bubbles. Head down positioning, adequate cruciate dural incision prior to cortex puncture and avoiding excessive egress of CSF are certain nuainces that will help to prevent such complication during the procedure.

Objectives: Apoplexy in a pineal cyst is a rare condition, with always headache or signs of increased intracranial pressure due to secondary hydrocephalus. Methods: We describe a patient with recent intra-cystal haemorrhage with vertigo, but without any headache symptoms. We also conducted a literature review. Results: This study focusses on a case report of a patient in whom apoplexy in the pineal cyst was detected as an incidental finding. Magnetic Resonance Imaging showed a recent haemorrhage within a 15 × 10 × 8 mm cyst of the pineal gland, without changes during follow-up. Clinically, however, the patient did not have any typical symptoms of headache or deterioration in the level of consciousness. Conclusion: Pineal apoplexy can also present as an asymptomatic incidental finding, or as the cause of transient vertigo and eye-movement disorder.

Intraventricular migration of a pellet is an unusual complication of a gunshot missile injury to the brain. Herein, we report the case of a 58 year-old man with a gunshot pellet that migrated by its mere tiny size, weight and cerebrospinal fluid pulsation from the lateral ventricle through the third ventricle, aqueduct of Sylvius to the fourth ventricle without accompanying clinical nor radiological manifestations. The pellet was thus managed expectantly. The patient was closely followed-up for short term complications such as hydrocephalus, infection and in the long run will be monitored for syrinx. He remained symptom-free and serial CT brain till 6 months after injury revealed the pellet still lodged in the fourth ventricle. Instances of similar phenomena reported in the literature are also reviewed and discussed.

Ependymomas constitute 4-6% of primary central nervous system tumors. Spinal ependymomas are most frequently found in intramedullary region but few cases of intradural extramedullary ependymoma have also been reported. We report a 24-year-old male patient with a suspected case of intradural extramedullary ependymoma. Magnetic resonance images of the lumbar spine depicted an intradural mass from L1-L4 level. The spinal lesion was isointense on T1-weighted images and hyperintense on T2-weighted images, relative to the spinal cord. Laminectomy L1-L4 with gross-total excision was performed. Histopathological examination was inconclusive but suggested the possibility of ependymoma. Neurological recovery was initially observed but after few months symptoms worsened.

Primary Narcolepsy is a sleep disorder with classical presentation showing symptoms of cataplexy, excessive daytime sleepiness, sleep paralysis, and Hypnogogic hallucinations. A rare case of secondary narcolepsy was seen in a patient with self-inflicted genital injury. A 30 year old male was referred to Psychiatry from Surgery for a self-inflicted incised wound on hydrocoele. Since last 1 year, he had multiple episodes of -- 1. Sudden falls while working 2. Sleep during daytime often at unusual places 3. Periods of unresponsiveness during which he was aware but unable to move. During hospital stay, all symptoms of Narcolepsy were noted several times, but prominent hallucinations were not consistently reported. Patient’s EEG was normal. MRI brain showed Gliosis at cervicomedullary junction.MRI spine was advised to examine the cervico-vertebral junction but patient was lost to follow-up. But from historyand investigations, based on DSM-IV-TR, Narcolepsy was diagnosed. It was concluded that he had secondary narcolepsy due to traumatic brain injury. As Self Inflicted Genital injury was done after hallucinations and sleep attack, it was considered to be part of Narcolepsy -a rare presentation. Narcolepsy typically begins in young adulthood mainly 2nd decades of life and causes adverse effects on quality of life of patients. Diagnosis relies on history of patient and objective details obtained from polysomnography and multiple sleep latency testing. Main treatment is symptomatic relief through medication, psycho education, and behavioural modification.