Early administration of thrombolysis can prevent myocardial necrosis: time is myocardium

A case is presented in which a 66-year-old man received thrombolysis for an acute ST elevation myocardial infarction (STEMI) within 6 minutes of developing chest pain. An ECG performed 10 minutes after thrombolysis showed complete resolution of the ST segment elevation and showed no other abnormality. An echocardiogram showed normal left ventricular function and there was no detectable myocardial necrosis, as evidenced by two negative troponin assays. The case clearly reinforces the benefits of the rapid delivery of thrombolysis when appropriate for patients with STEMI. Clinicians need to be aware of the benefits of early thrombolysis as laid out in the national service framework. Evidence for the early administration of thrombolysis, data from the Myocardial Infarction National Audit Project and the future with regard to improving thrombolysis times are discussed.

Neuronavigation in a developing country: a pilot study of efficacy and limitations in intracranial surgery

CONTEXT

Neuronavigation provides a patient-specific, three-dimensional (3-D) anatomy for preoperative planning and intraoperative navigation. However, the initial and maintenance costs are quite prohibitive, especially in the Indian scenario.

AIMS

To study the efficacy and limitations of neuronavigation, especially in the Indian scenario.

SETTINGS AND DESIGN

A prospective nonrandomized study.

MATERIALS AND METHODS

A total of 121 patients underwent intracranial surgery from 2002-2006, in which neuronavigation was used. In this, the initial part, we studied the efficacy and limitations of neuronavigation in the initial 37 patients. The efficacy of the image guidance was graded according to a point's scale in which points were awarded ranging from 0 to 3. Cranial image guided score (IGS) was calculated by the summation of grading during designing the flap/burr hole, delineation of the intraoperative anatomy, navigation and access to the lesion and resection / biopsy of the lesion or completion of the procedure. The scoring ranged from 0-12 and the utility of IGS in cranial neurosurgical procedures was calculated based on the total points for each surgery.

RESULTS AND CONCLUSION

Cranial image guidance was useful in a variety of operative steps. Intraoperative approach and navigation was relatively easier with an increase in perception of safety. Limitations of IGS include learning curve, cost and the phenomenon of brain shift. Drawbacks of the study included that this was a subjective rather than a truly objective study and the relatively lesser number of patients. We hope to conduct a larger study with randomization but the question of ethical approval would be a primary concern.

Endoscopic third ventriculostomy: 5 years' experience at the All India Institute of Medical Sciences

Endoscopic third ventriculostomy (ETV) is one of the efficacious surgical options available for obstructive hydrocephalus, and is preferable to a ventriculoperitoneal shunt in those eligible. We retrospectively studied 115 cases, who underwent ETV at our institute over the last 5 years. Thirty-eight patients were infants. Major indications for ETV were aqueductal stenosis (n = 60/115, 52.2%), Dandy-Walker malformation (15/115, 13%), associated arachnoid cyst (n = 13/115, 11.3%) and post-meningitic hydrocephalus (n = 12/115, 10.4%). Average duration of the follow-up was 10.6 months. Ninety-nine patients (86.1%) showed clinical improvement after surgery. Clinical improvement was seen in 27 out of 38 infants (71%) followed up. ETV is a highly effective tool in all age groups of patients for the management of hydrocephalus. Clinical features should be considered as indications of the success or failure of ventriculostomy in infants who have low-pressure hydrocephalus.

Giant mucoceles of the frontal sinus: a series and review

Giant mucoceles of the frontal sinus are a rare pathology but their recognition is important in the differential diagnosis of paediatric proptosis and fronto-orbital lesions. Four patients with giant mucoceles of the frontal sinus were retrospectively analyzed. All the patients were females in the paediatric age group presenting with massive cosmetically unacceptable bony swelling in the frontal region along with unilateral extra-axial proptosis. Radiological imaging revealed giant mucoceles of the frontal sinus with extracranial, orbital and anterior cranial fossa extension. One patient had co-existent craniofacial fibrous dysplasia. Single stage surgery was performed in three patients and two-stage surgery in one. Fronto-orbital craniotomy, removal of the posterior wall of the sinus, obliteration of the sinus and its ostium, dural repair and remodeling cranioplasty were performed. Histopathological examination revealed mucoceles in all, and co-existant fibrous dysplasia in one patient. All the patients made excellent cosmetic recoveries with complete resolution of their visual symptoms. Their clinical presentation, radiological manifestations and treatment modalities are analyzed and an extensive review of the literature is presented. Our case of giant frontal mucocele associated with fibrous dysplasia is furthermore the first such report in the existing medical literature.

Myxopapillary ependymoma of lumbosacral region with metastasis to both cerebellopontine angles: report of a rare case

INTRODUCTION

Myxopapillary ependymomas are low grade tumours that are known to recur locally even after complete excision, but metastasis to distant sites is extremely uncommon.

CASE REPORT

We report an unusual case of lumbo-sacral myxopapillary ependymoma in a 13-year-old boy with metastasis to both cerebellopontine angles. To the best of our knowledge, this is the youngest patient of metastatic myxopapillary ependymoma.

Effect of upper respiratory tract infection on AIR inhaled insulin pharmacokinetics and glucodynamics in healthy subjects

The suitability of employing AIR Inhaled Insulin (AIR Insulin; AIR is a registered trademark of Alkermes) during acute upper respiratory tract infection (URI) has not been determined. Twenty-one healthy, non-diabetic subjects were enrolled in a single-sequence, two-period, euglycemic clamp study. Subjects received a single 12 U-equivalent dose of AIR Insulin before rhinovirus (RV16) inoculation and during symptomatic infection. Spirometry was used to evaluate pulmonary safety. AIR Insulin exposure (the area under the immunoreactive insulin (IRI) concentration vs time curve from time zero until the IRI concentrations returned to the predose baseline value (AUC(0-t'))) and glucodynamic response (total amount of glucose infused (G(tot))) were comparable before and during RV infection (AUC(0-t') 46,300 vs 52,600 pmol min/l, P=0.21; G(tot) 61,800 vs 68,700 mg, P=0.42, respectively). Variability of pharmacokinetic and pharmacodynamic parameters did not change during URI; either did the number or intensity of adverse events. No significant change in forced expiratory volume or forced vital capacity was observed following AIR Insulin administration or during URI. The AIR Insulin system provides similar pharmacokinetic and glucodynamic responses under conditions of an experimentally induced RV infection and is regarded as suitable for use in diabetic patients during URIs.

Intracranial Pressure Changes During Valsalva Manoeuvre in Patients Undergoing a Neuroendoscopic Procedure

BACKGROUND

The Valsalva manoeuvre results in an increase in intrathoracic pressure which alters the systemic and cerebral circulations significantly. We decided to record changes in the intracranial pressure and cerebral perfusion pressure resulting from a Valsalva manoeuvre in anaesthetised patients.

METHODS

11 patients of either gender submitted to surgical neuroendoscopic procedures were studied. Standard general anaesthesia was maintained for the procedure in all the patients. Passive Valsalva manoeuvres were carried out by squeezing the bag of the closed breathing circuit to maintain an airway pressure of 20 cm H2O above peak inspiratory airway pressure for 10 seconds. The variables heart rate, mean arterial pressure, intracranial pressure and cerebral perfusion pressure were noted. The variables were recorded again after the surgical correction. All cardiovascular and cerebrovascular variables were compared using the Wilcoxon sign-rank test. We considered a value of p less than 0.05 to be statistically significant.

RESULTS

The median age of the 11 patients was 22 years (range: 15-43) and median weight was 50 kg (range: 30-78). On comparing the variables during the two Valsalva manoeuvres, we found significant changes in HR, ICP and CPP after the surgical correction. No complications were encountered in any of the patients.

CONCLUSION

There was a significant reduction in cerebral perfusion pressure during the Valsalva manoeuvre in both stages. This was a result of change in either the intracranial pressure or the mean arterial pressure. Although our patients did not suffer a clinically significant reduction in cerebral perfusion pressure and so had an uneventful recovery, the effect of Valsalva manoeuvre on cerebral perfusion pressure cannot be denied. The marked haemodynamic changes clearly warrant a cautious use of this manoeuvre in neurosurgical practice.

Pediatric intracranial aneurysms-clinical characteristics and outcome of surgical treatment

OBJECT

Intracranial aneurysms are rare in children and have different epidemiological, clinical, and morphological characteristics and outcome from those in adults.

MATERIALS AND METHODS

We analyzed demographic, clinical, radiologic features, treatment, and outcome in 55 patients <18 years of age, treated from Jan 1995 through December 2005.

RESULTS

Intracranial aneurysms in children below 18 years constituted 4% of all intracranial aneurysms. Internal Carotid artery (ICA) bifurcation was the commonest location. About half of the aneurysms were complex. Three-fourth of the patients required surgical treatment. Two patients died, constituting 5% mortality. Two patients (5%) had poor outcome, whereas the majority (90%) had a favorable outcome.

CONCLUSIONS

Pediatric aneurysms have male predominance, higher incidence of clinical features of mass effect or seizures, high incidence of large, traumatic/mycotic aneurysms, associated illnesses and ICH/IVH and hydrocephalus, better Hunt and Hess grades at presentation, ICA bifurcation as the commonest site, and better outcome than their adult counterparts.

Family of sperm associated antigens: relevance in sperm-egg interaction and immunocontraception

Overpopulation is a global problem of significant magnitude, with grave implications for the future. Development of new contraceptives is necessary, since current forms of birth control are unavailable, impractical and/or too expensive to many individuals due to sociological, financial, or educational limitations. A novel contraceptive strategy that is receiving considerable attention is that of immunocontraception. The targeting of antibodies to gamete-specific antigens implicated in sperm function, sperm-egg binding and fertilization offers an attractive approach to the growing global problem of over population. The sermatozoon has proteins that are unique, cell specific, immunogenic and accessible to antibodies. Immunological interaction with such molecules can cause block of sperm binding to the oocyte and thus fertilization. Modern biotechnologies (such as sperm proteomics, the determination of molecular and structural details of sperm proteins, and the modelling of protein-ligand interaction using X-ray and/or NMR structures to name a few) are trying to make intervention into the domain of human reproduction possible through the development of a variety of new methods and products to control fertility. The present article highlights the various sperm associated antigens involved in various aspects of sperm-egg interaction.

Haemodynamic changes after intracisternal papaverine instillation during intracranial aneurysmal surgery

Cerebral vasospasm remains a significant cause of mortality and morbidity after aneurysmal subarachnoid haemorrhage. Use of either intra-arterial or intracisternal papaverine as an alternative treatment of refractory cerebral vasospasm has been associated with various complications including haemodynamic instabilities. However, our search in literature did not reveal association of bradycardia and hypotension with the use of papaverine by either of these routes. Here, we describe a case of anterior communicating artery aneurysm with hydrocephalus. The patient underwent craniotomy and clipping of the aneurysm followed by third ventriculostomy. Instillation of papaverine at the surgical site caused significant haemodynamic changes possibly because of stimulation of hypothalamus in the third ventricle or vagal nuclei in the fourth ventricle, or even both. We recommend cautious use of intracisternal papaverine in such scenario especially when third ventriculostomy has been performed as an adjunct surgical procedure.

Endoscopic assisted excision of a retroclival arachnoid cyst presenting as hysterical breathlessness

BACKGROUND

Arachnoid cysts are benign developmental cysts occurring most commonly in the middle fossa. Posterior fossa arachnoid cysts are less common, with retroclival arachnoid cysts especially in the pediatric age group being rare.

PATIENTS AND METHODS

We present a case of a retroclival interpeduncular farachnoid cyst in a 10-year-old boy who presented with left-sided ptosis and episodes of hysterical breathlessness.

RESULTS

The surgical treatment involved endoscopic assisted microsurgical excision of the cyst and the child made an uneventful and complete recovery with complete cessation of breathlessness. The clinical presentation, etiopathogenesis, imaging characteristics and treatment modalities are discussed and the relevant literature reviewed.

Isolation and characterization of a haploid germ cell specific sperm associated antigen 9 (SPAG9) from the baboon

Previously, we cloned and sequenced a sperm specific antigen, designated as HSS (EMBL nomenclature human sperm associated antigen 9: hSPAG9) from human testis (Shankar et al.: Biochem Biophys Res Commun 243:561-565, 1998). The present study was conducted to isolate baboon proteomic homologue in order to find out whether the baboon can provide a suitable model for examining its immunocontraception effects. Baboon SPAG9 (bSPAG9) was cloned and sequenced from the baboon testis cDNA library. The baboon cDNA contained open reading frame encoding 760 amino acids. A 90.6 and 96.8% homology between baboon and human SPAG9 was found at protein and DNA levels. Analysis for tissue specificity by Northern blot procedure using various baboon tissues indicated that bSPAG9 was specifically expressed only in the baboon testis. Further, cell type expression analysis by in situ hybridization in baboon testis demonstrated the expression of bSPAG9 mRNA transcript only in the round spermatid suggesting haploid germ cell expression. Anti-human SPAG9 antibodies recognized the acrosomal compartment region of baboon sperm in indirect immunofluorescence (IIF). Flow cytometry analysis showed surface localization of bSPAG9 in live baboon sperm. The amino acid sequence data for nonhuman primate SPAG9 suggest that antibodies generated by vaccinating baboon with hSPAG9 will recognize nonhuman primate SPAG9, supporting the testing of SPAG9 contraceptive vaccine based on hSPAG9 in the nonhuman primate model.

Molecular cloning and characterization of the macaque sperm associated antigen 9 (SPAG9): an orthologue of human SPAG9 gene

The present study was conducted to isolate macaque proteomic homologue of human SPAG9 (EMBL nomenclature human sperm associated antigen 9: hSPAG9; Shankar et al., 1998: Biochem Biophys Res Commun 243:561-565) in order to find out whether the macaque can provide a suitable model for examining its immunocontraception effects. Macaque SPAG9 was cloned and sequenced from the macaque testis cDNA library. The macaque cDNA contained open reading frame encoding 712 amino acids. A 84.9% and 94% homology between macaque and human SPAG9 was found at protein and DNA levels. Northern analysis and RNA in situ hybridization experiments revealed testis- and stage-specific expressions of macaque SPAG9 mRNA, mainly confined to round spermatid suggesting haploid germ cell expression. Anti-human SPAG9 antibodies recognized native SPAG9 in macaque sperm extract in Western blotting and the acrosomal compartment region of macaque sperm in indirect immunofluorescence. Flow cytometry analysis further revealed surface localization of macaque SPAG9 in live macaque sperm. The amino acid sequence data for nonhuman primate SPAG9 suggest that antibodies generated by vaccinating macaque with hSPAG9 will recognize nonhuman primate SPAG9, supporting the testing of SPAG9 contraceptive vaccine based on hSPAG9 in the nonhuman primate model.

Duloxetine pharmacokinetics in cirrhotics compared with healthy subjects

OBJECTIVE

To compare the pharmacokinetics of single-dose duloxetine in cirrhotic and healthy subjects.

METHODS

An open-label inpatient study compared duloxetine pharmacokinetics in six subjects with moderate liver cirrhosis (Child-Pugh class B) to those in six healthy subjects. Subjects received a single 20 mg capsule of duloxetine following overnight fasting. Blood samples were collected up to 120 h post dose for determination of plasma concentrations of duloxetine and its major metabolites using a validated LC/MS/MS method. Plasma concentration-time data for duloxetine and its major metabolites were analyzed by noncompartmental methods. Specific pharmacokinetic parameters were assessed statistically using a mixed-effects model.

RESULTS

Duloxetine apparent clearance was significantly lower (24 vs 160 l/h, p < 0.05) and AUC values were substantially higher (775 vs 268 ng x (h/ml) in cirrhotic compared to healthy subjects. The half-life of duloxetine was about three times longer (47.8 vs 13.5 h) in cirrhotic than in healthy subjects (p < 0.05). In contrast, there was no significant difference in Cmax or apparent volume of distribution between the two groups. The metabolites exhibited lower levels and longer half-lives in cirrhotic subjects compared to healthy subjects. The lower clearance and slower elimination of duloxetine in cirrhotic individuals is likely attributable to impaired duloxetine metabolism.

CONCLUSIONS

The rate of duloxetine elimination is reduced for cirrhotic subjects, making dosage adjustments appropriate. Based on simulations, the duloxetine dose for at least an initial treatment period may need to be reduced and/or less frequently administered for patients with moderate cirrhosis.

Spontaneous subdural empyema in falciparum malaria: a case study

CLINICAL HISTORY

Malaria is one of the most common diseases in the tropical countries. Cerebral malaria is usually a diffuse symmetric encephalopathy with focal signs being unusual.

METHODS

We present a three-year old girl lapsing into unconsciousness following a seizure while undergoing treatment for malaria. Imaging revealed a large heterogenous density, left hemispheric acute subdural haematoma with brain herniation. Investigations revealed anaemia, thrombocytopenia and positive peripheral blood smear for falciparum malaria.

RESULTS

Treatment involved surgical evacuation of the clot and the associated subdural empyema, intravenous quinine and antibiotics.

CONCLUSION

This is the second case report of spontaneous subdural empyema in complicated falciparum malaria and highlights a rare but surgically manageable complication.

Myxopapillary ependymoma of the temporal lobe--report of a rare case of temporal lobe epilepsy

Myxopapillary ependymomas are a benign variant of ependymomas, occurring almost exclusively in the cauda equina region. We report an extremely rare case of myxopapillary ependymoma located in the left anterior temporal lobe. A 22-year-old man is presented with intractable seizures of 2 years duration with no focal neurologic deficits. Imaging of the brain revealed a well-circumscribed heterogeneous mass in the left anterior temporal pole with no connection to the ventricles. Imaging of the spine was normal. The patient underwent surgical removal of the tumor and at follow-up 4 months after surgery, there was improvement in his memory and speech along with complete cessation of seizures. Microscopic examination revealed the tumor to be a myxopapillary ependymoma, further confirmed by histochemical and immunohistochemical stains. To the best of our knowledge, this is the first documentation of myxopapillary ependymoma at this location and consequently, the first case to clinically present as intractable temporal lobe epilepsy.