Surgical Management of Craniospinal Axis Solitary Fibrous Tumors: A Single-Institution Case Series and Comprehensive Review of the Literature

BACKGROUND AND OBJECTIVES

Meningeal solitary fibrous tumors (SFTs) comprise 0.4% of primary central nervous system neoplasms and carry metastatic potential. Disease course and optimal management are largely unknown, and there is currently no literature rigorously describing neurological outcomes in surgically managed SFTs. We present one of the largest craniospinal SFT series, analyze patient outcomes, and extensively review the associated literature.

METHODS

All surgically managed SFTs at our institution between January 2005 and March 2023 were retrospectively reviewed. Patient demographics, tumor and radiographic features, treatment, and clinical outcomes were collected. Neurological function was quantified using Frankel grade and Neurologic Assessment in Neuro-Oncology scores. Descriptive statistics, multivariate analysis, log-rank test, and Kaplan-Meier survival analysis were performed.

RESULTS

Twenty-one patients satisfied inclusion criteria. Tumor locations included 15 supratentorial, three infratentorial, and three spinal. All patients underwent surgical resection, and 16 (76.2%) underwent radiation. Six (28.6%) patients had tumor recurrence, and three (14.3%) developed metastasis. Younger age and higher postoperative Frankel grade were significantly associated with increased overall survival (OS) ( P = .011, P = .002, respectively). All patients symptomatically improved or stabilized after surgery, and Neurologic Assessment in Neuro-Oncology score ( P = .001) and functional status significantly improved postoperatively (Karnofsky Performance Status: 65.2 ± 25.2 vs 91.4 ± 13.5, P = .001). Sex, adjuvant radiation, and extent of resection were not significantly associated with OS.

CONCLUSION

SFT of the central nervous system is a rare entity with a variable clinical course. Surgical resection was associated with improved postoperative functional and neurological status. Higher postoperative neurological function was significantly associated with OS. Further studies are warranted to validate a standardized treatment algorithm and investigate the efficacy of adjuvant radiation in SFT.

Meckel's diverticulum: Unusual cause of significant bleeding in an adult male

Meckel's diverticulum is a common congenital gastrointestinal malformation affecting 2% of the general population. Most affected patients are asymptomatic, and excessive bleeding causing a significant drop in hemoglobin count is an uncommon complication of Meckel's diverticulum, especially in adult patients. Herein, we present an adult case of Meckel's diverticulum that nearly led to hemodynamic instability. Laparotomy and segmental small bowel resection were critical in treating the patient.

Surgical management of symptomatic vertebral hemangiomas: a single institution experience and literature review

Vertebral hemangiomas (VHs), formed from a vascular proliferation in bone marrow spaces limited by bone trabeculae, are the most common benign tumors of the spine. While most VHs remain clinically quiescent and often only require surveillance, rarely they may cause symptoms. They may exhibit active behaviors, including rapid proliferation, extending beyond the vertebral body, and invading the paravertebral and/or epidural space with possible compression of the spinal cord and/or nerve roots ("aggressive" VHs). An extensive list of treatment modalities is currently available, but the role of techniques such as embolization, radiotherapy, and vertebroplasty as adjuvants to surgery has not yet been elucidated. There exists a need to succinctly summarize the treatments and associated outcomes to guide VH treatment plans. In this review article, a single institution's experience in the management of symptomatic VHs is summarized along with a review of the available literature on their clinical presentation and management options, followed by a proposal of a management algorithm.

Morphological Changes of Length of Prostate in Different Age Groups of Bangladeshi Cadaver

Benign prostatic hyperplasia is the most common prostatic problem for men older than age 50. It is a condition in men in which the prostate is enlarged but it is not cancerous. The prostate goes through 2 (two) main growth periods as a person ages. The first happens early in pubescence, when the prostate doubles in size. The second stage of growth begins around age twenty five and continues throughout most of a man's life. Benign prostatic hyperplasia often occurs with second growth phase. In the treatment of prostatic disorders, estimation of the length of prostate has been used to select the surgical approach. Transurethral resection of prostate (TURP) is preferred for small glands and open prostatectomy for larger ones. As the prostate gland is dependent on androgen for its growth, the prostatic length reflects the hormonal status of the subjects. This cross sectional descriptive study was conducted in Department of Anatomy, Mymensingh Medical College, Mymensingh, Bangladesh from April 2015 to September 2015 to find out the difference in length of the prostate of Bangladeshi people in relation to age. The present study was performed on 67 postmortem human prostate glands collected from the morgue in the Department of Forensic Medicine, Mymensingh Medical College, by non random purposive sampling technique. The specimens were collected from Bangladeshi dead body, age starting from 10-80 years. All the specimens were classified into 3(three) classes - Group A (upto 18 years), Group B (19-45 years) and Group C (>45 years) according to age. Dissection was performed according to standard autopsy techniques. The length of the prostate was measured and recorded. The mean±SD length of the prostate was 1.76±0.60cm, 2.65±0.56cm and 2.88±0.70cm in Group A, B and C respectively. The maximum mean length of the prostate was in Group C (2.88cm) and minimum was in Group A (1.76cm). It was observed that the length of the prostate was increased with age. Variance analysis shows that mean differences of length of the prostate were highly significant among all age groups. The length of prostate gland was found to be increase with age. For statistical analysis, variations between age groups were analyzed by students unpaired 't' test. The present study will help to increase the information pool on the length of prostate gland of Bangladeshi people.

Tuberculous pleural effusion

Despite prevention programs, tuberculosis is still endemic in developing countries. Extrapulmonary tuberculosis is increasing globally in the face of recent emergence of Human Immunodeficiency Virus (HIV) infection. Pleural tuberculosis is a common problem in daily clinical practice. We assessed 26 cases of tuberculous pleural effusion admitted in Bangabandhu Sheikh Mujib Medical University from 2002 to 2007. The diagnosis was based upon clinical examination, tuberculin reaction, imaging, pleural fluid analysis and response to antitubercular chemotherapy a surrogate clinical determinant. Apparently promising newer biochemical pleural fluid measurements were not utilized due to a number of limitations. The presenting symptoms found in this prospective analysis are fever (100%), nonproductive cough (73%), pleuritic chest pain (38%), loss of weight (38%) and shortness of breath (38%). A high index of suspicion after confident exclusion of malignancy and pneumonia is a clue to diagnosis. Out of 80 cases of extrapulmonary tuberculosis admitted during the study period, tuberculous pleural effusion constitutes 32.50%.

Endoscopic para-thyroidectomy: a new approach

Two patients (one male and one female) underwent endoscopic para-thyroidectomy for parathyroid adenoma at the Department of Surgery, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh. Three ports (one mid line and two laterals) were employed, a 10 mm telescope was used for the visualization and a harmonic scalpel was used for the dissection. To the best of our knowledge, there was no report of endoscopic para-thyroidectomy from Bangladesh. Both patients were fed on the first post operative day and discharged from the 4th and 8th operative day. Both patient's parathyroid hormone (PTH) level dropped to about one fourth the level in 12 to 20 minutes after enucleation (as compared to the immediate pre operative level). Endoscopic para-thyroidectomy appears to be a technically feasible patient friendly modality of treatment for the selected cases of para-thyroid pathology in experienced hand with excellent cosmetic outcome.

Extramedullary hematopoiesis and paraplegia in a patient with hemoglobin e-Beta thalassemia

Extramedullary hematopoiesis (EMH) occurs in patients with various hematologic disorders involving a chronic increase in the production of red blood cells, and is often associated polycythemia vera and sickle cell anaemia, but is less common with thalassemia especially with hemoglobin E-beta thalassemia. Spinal cord compression due to EMH is a extremely rare complication of thalassemia and may present with paraparesis or paraplegia with or without sensory impairment. Treatment options mostly include surgery and/or radiotherapy. Whereas cases presenting with paraplegia have been treated with either surgery or radiotherapy with equal frequency and efficacy, almost all reported cases with paraplegia have been treated with surgery with or without radiation therapy. We hereby report a case of hemoglobin E-beta thalassemia with paraplegia treated successfully with radiotherapy.

A fatal cobra-bite in a snake expert

A 35-year-old so called snake-expert from Thakurgaon district was admitted in Medicine department of Rangpur Medical College Hospital (RpMCH), Rangpur, Bangladesh on 2nd November 2007 with history of bites by a cobra snake. He was famous for his outstanding works to establish a snake farm first ever in Bangladesh. He had a collection of more than one hundred snakes of different species. He used to hatch eggs of the snakes, feed the young-snakes, collect venoms and sell those. Everyday many visitors used to visit his farm to watch exciting games with poisonous snakes. Several satellite television (TV) channels and some daily newspapers had covered him on different occasions. He was accidentally bitten by a newly caught hungry cobra snake while recording for a satellite TV channel. Following bites he was brought to the hospital three and a half hours later. By that time, neurotoxicity developed. Repeated doses of Anti Snake Venom (ASV) along with respiratory support and other supportive cares were provided. Despite utmost care feasible at RpMCH, patient expired around 49 hours later.

Typhoid Fever

Typhoid fever is one of the most common febrile illnesses encountered by the physicians in Bangladesh. Diagnosis is not difficult but has lately become a challenge due to changed clinical pattern of the disease, lack of adequate facilities for blood, stool, urine culture, excessive reliance on nonspecific Widal test and non availability of any reliable rapid diagnostic tests. Further, the indiscriminate and injudicious use of antibiotics for treating fever in undiagnosed febrile illnesses early has created problems to the physicians to reach to a diagnosis later on. This has also led to the emergence of high level resistance to many of the commonly used antibiotics in our country. Ciprofloxacin is often used empirically for treating the disease though there is already a high level resistance. In case the organism is in-vitro sensitive to ciprofloxacin but resistant to nalidixic acid, a much higher dose of drug is required to maintain the MIC which is 10 times higher than usual. Third generation cephalosporins (ceftriaxone and cefixime) are still the effective drugs for treating typhoid fever. The drug needs to be used in proper dose and duration to prevent emergence of resistance. Azithromycin though advocated by many as an alternative to ciprofloxacin in resistant cases, has recently lost its credibility due to emergence of resistance. We should not rely on Widal test in diagnosing typhoid fever. In a suspected case, the patient should not be prescribed any antibiotic without sending blood sample for culture sensitivity.

Cytomegalovirus induced hepatitis in an immunocompetent host

Cytomegalovirus (CMV) infection is most commonly sub clinical. In the immunocompromised host, primary CMV infection, reactivation and re-infection are all associated with significant morbidity and mortality. The clinical presentation of CMV infection in immunocompromised host varies according to the degree of immunocompromisation and to host factors. Populations at greatest risk of CMV infection and disease include individuals with HIV infection, transplant recipients, cancer patients receiving chemotherapy and burn patients. In the immunocompetent adult, primary CMV infection is usually asymptomatic but can result in a mononucleosis syndrome. The clinical course of the infection is usually mild, although a small percentage of patients suffer from protracted and severe fever. CMV infection in immunocompetent hosts may rarely be able to lead to severe organ specific complications. Most cases of CMV induced hepatitis occur in adults with severe immune deficiency. Only a few cases involving immunocompetent patients have been reported. But majority of the cases are anicteric or mildly icteric. Severe hepatitis is an uncommon presentation. We describe the first case reported in Bangladesh, of Cytomegalovirus induced severe hepatitis in an immunocompetent patient. The case was improved without the use of antiviral therapy.