Dispersion of repolarization increases after cardiac resynchronization therapy in patients who do not undergo left ventricular reverse remodelling

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Wellcome/EPSRC Centre for Medical Engineering

CardioInsight Inc.

Background

The effect of CRT on dispersion of repolarization and arrhythmic risk is unclear. LV epicardial pacing has been associated with increased dispersion of repolarization, which may be due to altered activation and repolarization sequence. However, while CRT-induced ventricular arrhythmias have been reported, evidence from large clinical trials suggest CRT has a favourable effect on arrhythmic risk, with a lower incidence of arrhythmia in patients who undergo LV reverse remodelling.

Purpose

To investigate the effect of CRT and LV reverse remodelling on dispersion of repolarization using electrocardiographic imaging (ECGi).

Methods

11 patients with heart failure and electrical dyssynchrony underwent ECGi after CRT implant and again at 6 months. Reconstructed epicardial electrograms were used to create maps of activation recovery intervals (ARI), an accepted surrogate for action potential duration, which were corrected for heart rate. LV ARI dispersion was calculated as the standard deviation of ARI across the LV epicardium. The methodology is summarized in figure 1.

Results

Mean age at implant was 74±10 years and 82% of patients were male. 64% had ischaemic aetiology of heart failure, and mean LV ejection fraction was 29±10%. 64% of patients had underlying LBBB, 28% had an RV-paced rhythm and 9% had RBBB. 8 patients had a ≥15% reduction in LV end-systolic volume (LVESV) with CRT at 6 months (volumetric responders). Example ARI maps for 1 patient are shown in figure 2A. There was a significant increase in LV ARI dispersion at 6 months compared to baseline (36.4±7.2ms vs 28.2±7.7ms; P=0.03) [Fig 2B]. In a multiple linear regression analysis, volumetric response was an independent predictor of relative change in LV ARI dispersion from baseline to 6 months (P=0.04). In a sub-analysis, for volumetric responders there was no significant difference in LV ARI dispersion between baseline and CRT at 6 months (36.4 ±6.1 vs 30.1±7.8 ms; P=0.1). In comparison, in volumetric non-responders there was a significant increase in LV ARI dispersion (38.3±1.2 vs 22.6±2.6 ms; P=0.01). The relative change in LV ARI dispersion from baseline to CRT 6-months was greater for volumetric non-responders compared to volumetric responders (70.7 ±21.3% vs 27.0 ±35.4%; P=0.04) [Fig 2C]. There was a moderate negative correlation between relative change in LV ARI dispersion and relative reduction in LVESV (R=-0.5), however this did not meet statistical significance (P=0.12) [Fig 2D].

Conclusion

CRT increases dispersion of repolarization at 6 months. However, this potentially arrhythmogenic effect of epicardial pacing was only observed in CRT non-responders, which is in keeping with previous evidence that LV reverse remodelling reduces risk of ventricular arrhythmia.

Assessing survival and re-hospitalisation following transvenous lead extraction in cardiac resynchronisation therapy devices depending on reimplantation timing: a propensity score matched analysis

Funding Acknowledgements

Type of funding sources: None.

Background

 Among patients undergoing transvenous lead extraction (TLE), differences in complication rate and 1-year mortality has been explored in patients with cardiac resynchronisation therapy (CRT) devices.  Longer term outcomes and the influence of timing of reimplantation of device, with respect to rehospitalisation and longer-term mortality is poorly understood. 

Purpose

 The purpose of this study was to evaluate whether early reimplantation following TLE in patients with CRT devices influenced survival and rehospitalisation.

Methods

 Clinical data from consecutive patients undergoing TLE in the reference centre between the years 2000 to 2019 were prospectively collected.  Patients surviving to discharge who were re-implanted with the same device were included. The cohort was split depending on whether or not they had a CRT device at time of explant.  The association between TLE in CRT patients and all-cause mortality and re-hospitalisation was assessed by Kaplan Meier estimates in a 1:1 propensity-score matched cohort, with a calliper of 0.10.  Early reimplantation was defined as reimplantation within 7 days of TLE, and late reimplantation as reimplantation after greater than 7 days of TLE.

Results

 Of 1005 patients included in the analysis, 285 (25%) had a CRT device.  After matching, 192 CRT patients were compared with 192 non-CRT patients.  Propensity scores were calculated using 39 baseline characteristics, including age, gender, co-morbidities, TLE indication, left ventricular ejection fraction, baseline creatinine and technical extraction data.  Mean follow up was 53.5 ± 38.3 months, mean age at explant was 67.7 ± 12.1 years, 83.3% were male and 54.4% had an infective indication for TLE.  In the matched cohort, there was no significant difference between the CRT and non-CRT group with respect to long-term mortality (hazard ratio [HR] = 1.01, 95% confidence interval [CI] [0.74-1.39], p = 0.093) or rehospitalisation (HR = 1.2 [0.87-1.66], p = 0.265).  A similar proportion of patients were reimplanted within 7 days in the CRT and non-CRT groups (59.4% vs 61.5%, p = 0.754).  In the matched non-CRT group, late reimplantation was associated with similar mortality to early reimplantation (HR = 1.33 [0.86-2.05], p = 0.208) and rehospitalisation (HR = 0.88 [0.53-1.45], p = 0.603).  In the matched CRT group, late reimplantation was associated with higher mortality (HR = 1.64 [1.04-2.57], p = 0.032) and rehospitalisation (HR = 1.57 [1.00-2.46], p = 0.049] (see figure).

Conclusion

  In this closely matched population, TLE in CRT patients resulted in similar long-term outcomes compared with non-CRT patients.  Early reimplantation post CRT explant was associated with reduced long-term mortality and rehospitalisation.  This suggests a longer duration without biventricular pacing post TLE may induce negative reverse-remodelling and should be avoided in a CRT population. Abstract Figure. Kaplan-Meier survival curves

Long-term survival following transvenous lead extraction: importance of indication and comorbidities

Funding Acknowledgements

Type of funding sources: None.

Background/Introduction: 

The significant rise in cardiac implantable electronic devices (CIED) has been paralleled by an increase in the number of procedures required for the removal of such devices and their associated leads.  High procedural success rates with low rates of major in hospital complications is well recognised.  Longer term mortality following transvenous lead extraction (TLE) is less well characterised. Long term outcomes are important as they should inform the decision making and consent process, especially in non-infected cases where there may not be a class I indication for lead removal. 

Purpose

 The purpose of this study was to evaluate the factors influencing survival in patients undergoing TLE depending on extraction indication.

Methods

 Clinical data from consecutive patients undergoing TLE in the reference centre between the years 2000 to 2019 were prospectively collected.  Only patients surviving to discharge were included. The total cohort was divided into groups depending on whether there was an infective or non-infective indication for TLE.  We evaluated the association of demographic, clinical, device related and procedure-related factors on mortality.

Results

 A total of 1151 patients were included in the analysis.  632 (54.9%) and 519 patients (45.1%) were for infective and non-infective indications respectively. Analysis of long-term outcomes on the total cohort (mean 66-month follow-up) revealed a mortality of 34.1% (392 deaths).  A higher proportion of patients died in the infection vs the non-infection group (38.6% vs 28.5%, p < 0.001).  Local infection (hazard ratio [HR] = 1.4, 95% confidence interval [CI] [1.12-1.75]) was associated with similar long-term mortality risk as systemic infection (HR = 1.3, CI[0.99-1.72]). Multivariate analysis demonstrated increased risk of mortality with higher age (HR = 1.05, CI[1.04-1.07]), eGFR < 60ml/min/1.73m2 (HR = 1.55, CI[11.22-1.97]), higher cumulative co-morbidity burden (HR = 1.15, CI [1.06-1.23], and reduced risk per percentage increase in LVEF (HR = 0.98, CI[0.96-1.00]). Kaplan-Meier survival analysis demonstrated statistically worse prognosis in patients with a higher number of leads extracted and increasing co-morbidities.

Conclusion

  Long-term mortality for patients undergoing TLE remains high. Consensus guidelines recommend evaluating risk for major complications when determining whether to proceed with TLE. This study suggests assessing longer-term outcomes when considering TLE, particularly for non-infective indications. Abstract Figure.

Pilocytic Midbrain Astrocytoma Presenting with Fresh Bleed after Twenty-one-years Survival Following First Surgery: A Unique Case of Longest Brainstem Glioma Survival

Brainstem glioma usually carries a poor prognosis and prolonged survival is very infrequent. In a detailed Pubmed, Medline search for prolonged survival, authors could got a longest survival only up to seventeen years, reported by Umehara et al, who was subjected to gamma knife therapy and got symptomatic, MRI brain reveled large tumor growth during pregnancy necessitating emergency surgery and histopathological diagnosis was pilocytic astrocytoma. Authors report an interesting case of midbrain glioma diagnosed 21 years back, who underwent gross resection in the year 1993, histopathology was pilocytic astrocytoma, WHO grade I, and received gamma knife surgery for residual subsequently and he presented with sudden onset left sided hemiplegia on the current admission. The cranial MRI imaging revealed an infarct involving right hemi midbrain, contrast MRI brain revealed no residual glioma. To the best knowledge of authors such prolonged survival is not reported with a case of brainstem glioma survived twenty- one years with non residual tumor on the last imaging study represents first case of its kind in the western literature and probably developed hemiplegia due to bleed, highlighting bleed as delayed complication following gamma knife therapy for cranial tumors.

Giant Bilateral Calvarial Hyperostosis Secondary to Small Unilateral Frontal Meningioma

A 28-year-old male patient presented to us with bilateral frontal hyperostosis associated with a small unilateral frontal intracranial meningioma. He underwent successful excision of the involved bone and repair of the large cranial defect using a titanium mesh. Histological examination revealed tumor infiltration of the overlying bone. Surgical challenges in the management of such a case are also discussed.

Demonstration of Brain Expansion in Cases of Chronic SDH during Admission Leads to Decreased Rates of Recurrence

While being considered a simple procedure among the wide spectrum of neurosurgical procedures, the surgical management of chronic subdural hematoma (SDH) still possesses a degree of variability. Present concepts of production versus absorption of chronic SDH fluid has led to practitioners differing in the use of drains, the treatment of inner membrane, the flushing of the subdural cavity, and the perioperative decision making for cases with comorbidities and a history of anticoagulant/antiplatelet usage. In this article, we present the management of chronic SDH over a period of 15 months using the principles followed at our center. In 60 patients of chronic SDH, with the use of drains, we waited for radiological demonstration of brain expansion before drain removal and discharge. In our experience, this has led to better prognostication and very low recurrence rates, particularly in patients with comorbidities and on anticoagulant/ antiplatelet medication.

Primary dorsal spine primitive neuroectodermal tumor in an adult patient: Case report and literature review

Primary spinal primitive neuroectodermal tumor (psPNET) is a rare entity with few cases reported in literature. We report a case of a 50-year-old female who presented to us with paraplegia and was diagnosed with extradural dorsal spine psPNET. The diagnosis was not suspected at presentation or on radiology but was established on histopathological examination. It is important to distinguish it from central nervous system primitive neuroectodermal tumors and from other spinal tumors since it follows a different clinical course and therapeutic outcome.

Comparison of Stereotactic and Ultrasound-guided Biopsy of Solid Supratentorial Tumor: A Preliminary Report

Introduction:

The computed tomography (CT) guided stereotactic biopsy (STB) is considered as method of choice for biopsy of intracranial mass lesions. However, it's disadvantages are frame fixation, time requirement for transportation between CT scan suit to the operation theater with added much higher equipment cost in the relatively resource scarred developing country. Ultrasound-guided biopsy (USGB) is relatively simpler, economical, less time consuming, and real-time procedure.

Clinical Materials and Methods:

Thirty-seven consecutively admitted patients with supratentorial brain tumors, who underwent biopsy of the lesion using CT compatible stereotactic and ultrasound-guided (USGB) procedure formed cohort of the study. Based on location and size of the lesions, the cases were divided into two groups, superficial and deep. Twenty-two patients underwent ultrasound-guided biopsy and 15 with STB.

Results:

The diagnostic yield of STB was 93% and 91% for ultrasound-guided biopsy. The mean operation time of STB group was 149.00 min and 94 min for USGB, which was statistically significant. Two cases in each group developed hematoma; however, one case in USGB group needed surgical evacuation. The real-time monitoring detected two hematoma intraoperatively, which were further also confirmed on postoperative CT scan head.

Conclusions:

The ultrasound-guided biopsy procedure (USGB) was simple, relatively shorter time-consuming procedure and equally efficacious and utilizing economical equipment and can act as a safer alternative to CT STB process for biopsy of the intracranial mass lesion. Furthermore, USGB also provided intra-operative real-time monitoring, which provided clue for close monitoring in the postoperative period after completion of biopsy to look for development of fresh hematoma development not only at the biopsy site but also along the biopsy track and adjoining area. Perhaps, a longer period of ultrasonic monitoring following the procedure would be of greater help to detect hematoma formation, which is one of the most common complications of the biopsy procedure.

Acute unilateral post-operative submandibular sialadenitis following posterior cranial fossa surgery

Extreme degree of rotation and flexion of the head during posterior fossa surgeries can lead to acute post-operative submandibular sialadenitis that can cause respiratory compromise. Identification of this problem is vital to prevent deterioration in the early post-operative period. This condition responds well to conservative management provided airway obstruction is taken care of. We discuss a case of a 63-year-old female, with a left side vestibular schwannoma who developed airway obstruction in post-operative period due to swelling of right submandibular gland. Various possible mechanisms leading to this condition and related literature are briefy reviewed.

Stem cell therapy for stress urinary incontinence: a systematic review in human subjects

PURPOSE

To systematically evaluate the current evidence on the safety and efficacy of stem cell therapy (SCT) in stress urinary incontinence (SUI) to allow objective comparison with existing surgical techniques.

METHODS

Systematic literature search of Medline from years 1946-2012 using terms: "stem", "cell", "stress", "urinary", and "incontinence". Included studies presented empirical data on the treatment of SUI using SCT.

OUTCOMES

adverse events, incontinence, quality of life, urodynamic, transurethral ultrasound and urethral EMG findings.

RESULTS

Eight studies met inclusion criteria (seven observational and one randomized). Quality score: median 10.75 of 20 (range 2-12.5). Adverse events: one patient had bladder perforation and two procedures could not be completed due to pain. Temporary urinary retention and cystitis were also reported. Incontinence score: Four studies describe significant improvement. Quality of life: significant improvement in four studies. Urodynamic outcomes: four studies show significant improvement in contractility of urethral sphincter; three studies demonstrate no change in bladder capacity and significant reduction in residual volume; significant improvement in urinary flow three studies, although two found no difference; increase in leak point pressure and detrusor pressure in three studies. Urethral ultrasound: three studies found significant increases in rhabdosphincter thickness and contractility. Urethral EMG: two studies found significant increases in the EMG at rest and at contraction.

CONCLUSION

Data suggest that SC treatment for SUI is safe and effective in the short term. However, the quality and maturity of the data are limited. Robust data from better quality studies comparing this to current surgical techniques are needed.

Spinal dural arterio-venous fistula: clinico-radiological profile and outcome following surgical occlusion in an Indian neurosurgical center

BACKGROUND

Spinal dural arteriovenous fistula (SDAVF) is a common type of spinal vascular lesion. However, there has not been any published study on its clinico-radiological characteristics or surgical outcome from India.

AIM

The aim of this study was to determine the clinico-radiological features of patients with SDAVF, outcomes following surgical ligation of the fistula and the various factors involved.

MATERIALS AND METHODS

Patients who were operated for SDAVF were studied for demographic details, symptoms, clinical severity, radiological features and neurological outcome in the form of improvement in gait disability grades. Appropriate statistical tests were performed.

RESULTS

There were 22 (19 males, 3 females) patients of SDAVF who underwent surgical ligation with a mean age of 55 years. The mean duration of symptoms at presentation was 15 months. Three patients had acute onset while the rest had insidious onset of symptoms. Out of the 22 patients, 11 (50%) had motor weakness as the first symptom, 13 (59%) were bedridden and 19 (86.4%) had bladder involvement at presentation. Thirteen patients had fistulae in thoracic spine, whereas eight had fistulae in the lumbar spine. All had a favorable outcome in the form of at least non-progression of gait disability (14 had improvement while 8 had stabilized). The improvement was non-significantly associated with younger age, acute onset, ambulant status and fistula below T9. It was inversely associated with pain as the first symptom and fluctuant clinical course.

CONCLUSION

Surgical occlusion of SDAVF is usually associated with either improvement or stabilization of motor weakness.

ATM-NFκB axis-driven TIGAR regulates sensitivity of glioma cells to radiomimetics in the presence of TNFα

Gliomas are resistant to radiation therapy, as well as to TNFα induced killing. Radiation-induced TNFα triggers Nuclear factor κB (NFκB)-mediated radioresistance. As inhibition of NFκB activation sensitizes glioma cells to TNFα-induced apoptosis, we investigated whether TNFα modulates the responsiveness of glioma cells to ionizing radiation-mimetic Neocarzinostatin (NCS). TNFα enhanced the ability of NCS to induce glioma cell apoptosis. NCS-mediated death involved caspase-9 activation, reduction of mitochondrial copy number and lactate production. Death was concurrent with NFκB, Akt and Erk activation. Abrogation of Akt and NFκB activation further potentiated the death inducing ability of NCS in TNFα cotreated cells. NCS-induced p53 expression was accompanied by increase in TP53-induced glycolysis and apoptosis regulator (TIGAR) levels and ATM phosphorylation. siRNA-mediated knockdown of TIGAR abrogated NCS-induced apoptosis. While DN-IκB abrogated NCS-induced TIGAR both in the presence and absence of TNFα, TIGAR had no effect on NFκB activation. Transfection with TIGAR mutant (i) decreased apoptosis and γH2AX foci formation (ii) decreased p53 (iii) elevated ROS and (iv) increased Akt/Erk activation in cells cotreated with NCS and TNFα. Heightened TIGAR expression was observed in GBM tumors. While NCS induced ATM phosphorylation in a NFκB independent manner, ATM inhibition abrogated TIGAR and NFκB activation. Metabolic gene profiling indicated that TNFα affects NCS-mediated regulation of several genes associated with glycolysis. The existence of ATM-NFκB axis that regulate metabolic modeler TIGAR to overcome prosurvival response in NCS and TNFα cotreated cells, suggests mechanisms through which inflammation could affect resistance and adaptation to radiomimetics despite concurrent induction of death.

Dengue hemorrhagic fever: a rare cause of pituitary tumor hemorrhage and reversible vision loss

Dengue hemorrhagic fever leading to hemorrhage in pituitary adenoma is not reported till date: We herein report the first case of bilateral visual loss secondary to pituitary adenoma hemorrhage associated with dengue hemorrhagic fever. Urgent transnasal trans sphenoidal decompression of the macroadenoma prevented permanent visual loss in this patient. Pituitary apoplexy should be considered as differential diagnosis of visual deterioration apart from retinal hemorrhage, maculopathy, and optic neuropathy in cases of dengue hemorrhagic fever. Early decompression of optic nerves helped in the restoration of vision.

August 2002: 21-year-old male with cystic intracerebral tumor

The August 2002 COM. A 21-year-old male presented with a single episode of generalized tonic clonic seizures. Radiology revealed a cystic tumor with mural nodule suggestive of a pilocytic astrocytoma. However, histopathological examination and electron microscopy revealed features of an intracerebral schwannoma. Therefore, although rare, in an intracerebral cystic lesion with mural nodule, the possibility of an intracerebral schwannoma should be entertained. This is important because this is a benign tumor with favourable response to resection.

A cross-sectional evaluation of computer literacy among medical students at a tertiary care teaching hospital in Mumbai, Bombay

BACKGROUND

Computer usage capabilities of medical students for introduction of computer-aided learning have not been adequately assessed.

AIM

Cross-sectional study to evaluate computer literacy among medical students.

SETTINGS AND DESIGN

Tertiary care teaching hospital in Mumbai, India.

MATERIALS AND METHODS

Participants were administered a 52-question questionnaire, designed to study their background, computer resources, computer usage, activities enhancing computer skills, and attitudes toward computer-aided learning (CAL). The data was classified on the basis of sex, native place, and year of medical school, and the computer resources were compared. The computer usage and attitudes toward computer-based learning were assessed on a five-point Likert scale, to calculate Computer usage score (CUS - maximum 55, minimum 11) and Attitude score (AS - maximum 60, minimum 12). The quartile distribution among the groups with respect to the CUS and AS was compared by chi-squared tests. The correlation between CUS and AS was then tested.

RESULTS

Eight hundred and seventy-five students agreed to participate in the study and 832 completed the questionnaire. One hundred and twenty eight questionnaires were excluded and 704 were analyzed. Outstation students had significantly lesser computer resources as compared to local students (P<0.0001). The mean CUS for local students (27.0±9.2, Mean±SD) was significantly higher than outstation students (23.2±9.05). No such difference was observed for the AS. The means of CUS and AS did not differ between males and females. The CUS and AS had positive, but weak correlations for all subgroups.

CONCLUSION

The weak correlation between AS and CUS for all students could be explained by the lack of computer resources or inadequate training to use computers for learning. Providing additional resources would benefit the subset of outstation students with lesser computer resources. This weak correlation between the attitudes and practices of all students needs to be investigated. We believe that this gap can be bridged with a structured computer learning program.

Surgical considerations for 'intrinsic' brainstem gliomas: proposal of a modification in classification

BACKGROUND

Brainstem gliomas are highly heterogeneous tumors both in their clinical manifestation and in their pathology. Despite significant advances in the surgery for brainstem gliomas many aspects of this pathology are still unclear.

OBJECTIVE

To evaluate the clinical, radiological and surgical outcome of 40 focal 'intrinsic' brainstem gliomas and propose a surgical strategy-oriented classification.

MATERIALS AND METHODS

A total of 40 focal 'intrinsic' ("expanding variety") tumors have been operated over a period of 8.5-years (January 1998-June 2007). Our criteria included patients with (1) well-defined gadolinium enhancing tumor; (2) relatively long duration of symptoms (> six months) and (3) good neurological functional status and independent for all activities of daily living. The cutoff size of 2 cm was not rigidly adhered to.

RESULTS

The 'intrinsic' brainstem tumors were classified into three types: Expanding, diffuse infiltrative and pure ventral varieties. Only patients with expanding variety of brainstem gliomas were subjected to surgery, mean age 19.2 years (range 4-55 years) and male to female ration mean: 3:2). The tumor location included pons (n=19), midbrain (n=13) and medulla (n=8). Surgical approaches included midline suboccipital (n=28), retromastoid (n=7), subtemporal (n=3) and supracerebellar-infratentorial (n=2). Thirty-two cases with 'diffuse infiltrative' and 'pure ventral' variety were given radiotherapy only. Histology pathology revealed pilocytic variety (n=10), Grade II (n=17) and Grade III (n=13). There was one death in the surgical series (due to aspiration). Complications included meningitis (n=2), wound infection (n=1), chest infection (n=5) and transient mutism (n=1). Follow-up ranged from 3-68 months. Overall, 36 improved /remained same and three worsened in their clinical status at the time of discharge.

CONCLUSION

The surgical management of intrinsic brainstem tumors presents a surgical challenge; radical excision yielded a good outcome in the majority of cases. The authors propose a classification system for 'intrinsic' brainstem tumors for defining surgical strategy.

Awake craniotomy versus surgery under general anesthesia for resection of intrinsic lesions of eloquent cortex—A prospective randomised study

OBJECTIVES

Complete removal of a brain tumor without inflicting neurological deficits is a desirable end result in neurosurgical practice. Currently no prospective randomized surgical series in the literature exists comparing tumor resection under general versus local anesthesia awake surgery may achieve more aggressive tumor resection and minimize postoperative neurological morbidity.

PATIENT AND METHODS

We thence conducted a prospective randomized comparative study of results of surgery under awake versus surgery under general anesthesia for intrinsic eloquent area lesions. Fifty-three patients with intrinsic brain tumors in eloquent areas were prospectively randomized (26 patients in awake group and 27 for surgery under general anesthesia). At 3 months follow up, 23% patients in awake group had permanent deficits compared to 14.8% in GA group.

RESULTS

More than 90% tumor excision was observed in 57% patients in awake group versus 73.7% in GA group.

CONCLUSIONS

The mean operative time, blood loss was found to be was found to be less in GA group patients than in awake group. Better tumor cytoreduction, neurological improvement was seen in GA group (motor improvement in 35.7%, speech improvement in 62.5%) than in awake group patients (motor improvement in 18.7%, speech improvement in 14.3%).

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.

Economics of head injuries

Head injuries account for significant proportion of neurosurgical admissions and bed occupancy. Patients with head injuries also consume significant proportions of neurosurgical resources. A prospective 6-month study has been carried out to evaluate the expenditure incurred on head injury patients in a modern neurosurgical center equipped with state of the art infrastructure. Costing areas included wages / salaries of health care personnel, cost of medicines / surgical items / crystalloids, general store items, stationary, all investigation charges, equipment cost, overhead building cost, maintenance cost, electricity and water charges and cost of medical gases, air conditioning and operation theatre expenses. Expenditure in each area was calculated and apportioned to each bed. The statistical analysis was done using X2 test. The cost of stay in ward was found to be Rs. 1062 / bed / day and in neurosurgical ICU Rs. 3082 / bed / day. The operation theatre cost for each surgery was Rs. 11948. The cost of hospital stay per day for minor, moderate and severe head injury group was found to be Rs. 1921, Rs. 2569 and Rs. 2713 respectively. The patients who developed complications, the cost of stay per day in the hospital were Rs. 2867. In the operative group, the cost of hospital stay per day was Rs. 3804. The total expenditure in minor head injury was Rs. 7800 per patient, in moderate head injury was Rs. 22172 per patient, whereas in severe head injury, it was found to be Rs. 32852 per patient. Patients who underwent surgery, the total cost incurred was Rs. 33100 per operated patient.

The enigmatic origin of subfrontal schwannomas: report of a case without hyposmia

Subfrontal schwannomas are rare intracranial tumors. Most of them are associated with hyposmia/anosmia. The source of origin of these tumors is still incompletely understood. We report a 23-year-old male who presented with recurrent focal motor seizures, but had no hyposmia. The tumor was completely removed by a subfrontal approach. Relevant literature has been reviewed.

Recurrence in craniopharyngiomas: Analysis of clinical and histological features

The aim of this study was to investigate the recurrence patterns and significance of various clinical and histological features as predictors of recurrence in craniopharyngiomas. A series of 234 craniopharyngiomas (156 males, 78 females; age range 1.6-65 years) was reviewed. The mean follow-up period was 18.53 months (range 1-120 months). Peri-operative mortality was 7.4% and tumor recurrence was observed in 26 patients (20.3%). Of the patients with recurrence, one had total tumor excision (recurrence-free survival (RFS) 14 months), four had near-total excision (mean RFS 18.2 months) and 21 had subtotal tumor excision (RFS for symptomatic recurrence 7.1 months). Histologically, an adamantinous pattern was seen in 81.4% of cases and a papillary pattern was seen in 18.6%. Brain tissue was included in 67 cases and brain invasion was noted in 44 (all were of adamantinous histology). No correlation was noted between histopathological subtyping or brain invasion and recurrence. The significant clinical factors predictive of recurrence included the extent of resection, tumor size greater than 4 cm and cystic tumors.

Chordoid meningioma, an uncommon variant of meningioma: a clinicopathologic study of 12 cases

AIMS

The study has been undertaken to document the clinicopathological features of 12 cases of chordoid meningioma, operated at All India Institute of Medical Sciences during 1996 to June 2005.

METHODS

Clinical information was retrieved from the records of our Neurosurgery Department. The cases were stained with H&E, Periodic Acid Schiff (PAS) with and without diastase, mucicarmine, giemsa, toluidine blue, alcian blue, reticulin and Masson trichrome. Immunohistochemistry for pancytokeratin, epithelial membrane antigen, vimentin, glial fibrillary acidic protein, MIB-1, Leucocyte common antigen (LCA), CD-3 and CD-20 was done in all cases.

RESULTS

The age ranged from 12-67 years (mean 34.2 years) and three of them occurred in < 18 years. Male to female ratio was 1:1.4. The duration of symptoms varied from 3.5 months to 5 years (mean 14.1 months). No systemic symptoms were noted. The location of tumor in eight cases was in the supratentorial and rest four in the infratentorial compartments. Interestingly, two cases were in intraventricular location, one in the lateral ventricle and other in the fourth ventricle. Microscopic examination showed lobulation with chordoid elements constituting > 95% of the entire tumor area in 11 of the total 12 cases. In one case, chordoid pattern constituted about 30% of the total tumor area; the rest was predominant meningothelial (60%). Mild to severe lymphoplasmacytic cell infiltrate was present in all cases. The histochemical stains showed the pattern of acidic mucin and interestingly revealed the presence of mast cells both in connective tissue stroma and epithelial cell islands. The inflammatory infiltrate was B-cell predominant. MIB-1 labeling index was low (< 2%) in all cases except two, which showed LI of 6% and 8%. Strong diffuse immunoreactivity for vimentin and focal positivity for epithelial membrane antigen was noted in all cases.

CONCLUSIONS

Chordoid meningiomas are predominantly tumors of young adults with predilection for supratentorial location. Intraventricular location, absence of systemic manifestations despite the presence of abundant B-lymphocytes, presence of mast cells and low MIB-1 LI are some of the interesting findings in the present series, which need documentation. Hence, larger number of cases with adequate follow-up data need to be studied further to establish the clinical significance of this variant.

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.

Recurrence in pediatric craniopharyngiomas: analysis of clinical and histological features

OBJECTIVE

The purpose of this study was to investigate the recurrence pattern and significance of various clinical and histological features as predictors of recurrence in pediatric craniopharyngiomas.

METHODS

A series of 116 pediatric craniopharyngiomas (68 boys and 48 girls; age range, 1.6-18 years) was reviewed. Mean follow-up period was 18.53 months. Tumors recurred in 15 patients within 96 months [mean recurrence-free survival (RFS), 12.67 months]. Of the recurrence cases, 2 had complete (mean RFS, 16 months) and 13 had subtotal tumor excision (mean RFS, 9.03 months). Histologically, an adamantinous pattern was seen in 95% of cases, whereas a papillary pattern was noted in 5%. Brain tissue was included in 41 cases. In 32 of 41 cases, brain invasion was noted, and all were of adamantinous histology. No correlation was noted of histopathological subtyping or brain invasion with recurrence.

CONCLUSIONS

The significant clinical factors associated with recurrence included extent of resection, tumor size >4 cm, and cystic tumors.

Recurrent lymphocytic hypophysitis in a woman 27 years after subtotal adrenalectomy for hypercortisolism possibly of autoimmune origin

Lymphocytic hypophysitis commonly occurs in females in peripartum period but several unusual presentations have been reported. Here we report a rare case of recurrent lymphocytic hypophysitis in a woman who had subtotal adrenalectomy for hypercortisolism 27 years back. Polyglandular autoimmune endocrinopathy with an uncommon combination of Cushing's syndrome and recurrent hypophysitis is a strong possibility in this case. Treatment with steroids has been found to have beneficial effect.

Role of shunt surgery in pediatric tubercular meningitis with hydrocephalus

This study was designed to evaluate the indications for ventriculoperitoneal shunting in cases of children with tubercular meningitis, presenting with hydrocephalus. Thirty seven children (less than 18 years of age) of tubercular meningitis with hydrocephalus (TBMH) who underwent ventriculoperitoneal shunting over a three year period (1999 to 2001) were included in the study. Sixteen (43%) children were Palur stage II, 15 (40%) stage III, and 6 (16%) stage IV. Fifteen (40%) children had received antitubercular therapy for less than 4 months and 17 (46%) received therapy for more than 4 months prior to presentation. Five (14%) children had not previously received antitubercular therapy. Shunt related complications occurred in 11 (30%) children and 3 children had undergone revision of the shunt multiple times. Good outcome was seen in 16 (43%) children. Thirteen (35%) had moderate disability and 6 (16%) had severe disability at 3 months of follow up. 62% (n =10) children in grade II had a good outcome compared to 40% (n = 6) in grade III. All six children in grade IV had a poor outcome. 2 children, both having multiple infarcts, died and the remaining 4 were left with severe disability. We recommend shunt placement in all children of grade II and III TBMH as this policy has yielded the best results. For grade IV children external ventricular drainage, followed by shunting if improvement occurs remains the most cost-effective procedure.

Memory and intelligence outcome following surgery for intractable temporal lobe epilepsy: relationship to seizure outcome and evaluation using a customized neuropsychological battery

The main objectives of this prospective study were to (1) assess memory and intelligence outcome following surgery for intractable temporal lobe epilepsy, (2) correlate this with seizure outcome and side of surgery, and (3) perform (1) and (2) using an indigenously developed battery customized to the Indian population. Prior to use in our epilepsy surgery program, the test-retest and interexaminer variance reliability of this battery had been established in both normal and cognitively compromised populations. The memory scores were overall rather than material-specific. The battery was administered to right-handed adults undergoing surgery for intractable temporal lobe epilepsy without any evidence of opposite temporal lobe abnormality, both presurgery and postsurgery at a mean follow-up of 8 months. Twenty-five consecutive patients were included; 13 underwent right and 12 underwent left temporal surgery. Seizure outcome was assessed using Engel's classification. Among 13 patients who underwent right temporal surgery, although 4 patients with poor seizure outcome had insignificant changes in scores, 7 of 9 patients with good seizure outcome exhibited considerable (> 20% over preoperative) improvement in their memory and intelligence scores. Statistical analysis using Student's t test and the Mann-Whitney test revealed that the patients who underwent right temporal surgery with good seizure outcome had significant improvement in both memory (P = 0.007) and intelligence (P = 0.043) scores compared with those with poor seizure outcome. In contrast, patients who underwent left temporal surgery had no significant change in cognitive scores irrespective of seizure outcome. Cognitive improvement seems to occur in patients with good seizure outcome following nondominant temporal lobe surgery for intractable epilepsy with no evidence of pathology in the opposite temporal lobe. The same finding was not observed in patients undergoing left temporal surgery.

Giant intraparenchymal neurocysticercosis: unusual MRI findings

We report a case of surgically proven giant neurocysticercosis (NCC). MR imaging revealed an unusually large solitary parenchymal cystic lesion showing signal intensity similar to CSF on all pulse sequences, with internal septations and a small nodule in the anterior aspect of this lesion compatible with this diagnosis. Identification of a scolex in a cystic lesion with CSF intensity plays a key role in the diagnosis of NCC. The presence of internal septations is an atypical feature.

Arachnoid cyst presenting as subdural hygroma

Arachnoid cysts are developmental lesions which are usually asymptomatic or may present with a variety of clinical features. Subdural hygroma is an extremely unusual complication associated with arachnoid cysts. A case of subdural hygroma that developed after the rupture of an asymptomatic middle cranial fossa cyst, following minor head injury is reported.

Efficacy and results of expansive laminoplasty in patients with severe cervical myelopathy due to cervical canal stenosis

AIMS AND OBJECTIVES

To assess the efficacy and results of expansive laminoplasty in advanced (Nurick's Grade III or greater) cervical myelopathy.

MATERIALS AND METHODS

We reviewed data in 24 patients who underwent cervical laminoplasty from January 1999 to December 2002. Nuricks grading was used for quantifying the neurological deficits and outcome analysis was done using Odom's criteria. A modified Hirabayashi's open door laminoplasty was done using Titanium miniplates and screws in 22 patients, autologous bone in one and hydroxyapatite spacer in one patient.

OBSERVATIONS

There were 3 females and 21 males with a mean age of 56 years (range 39-72 years). Four patients presented in Nuricks Grade III, 15 in Grade IV and five in Grade V. MR imaging showed MSCS in 21 cases, OPLL in nine cases and ligamentum flavum hypertrophy in nine cases with cord signal changes being present in 19 cases.

RESULTS

All patients with duration of symptoms less than three years, and 50 % with duration ranging from three to six years had improvement by at least one Nurick's grade following surgery. Eighty-seven per cent Grade IV patients (ambulatory with support) improved to Grade III (ambulatory without support) following laminoplasty. Using Odom's criteria, 23 patients (95.8%) had a good to fair outcome.

CONCLUSIONS

Cord decompression with expansive laminoplasty using titanium miniplate fixation may improve the neurological outcome even in patients presenting late, and improvement by even one grade may have major 'quality of life' benefits for these patients.

Ganglioglioma of the spinal cord: Report of two cases and review of literature

Ganglioglioma can involve any part of the central nervous system. Mostly ganglioglioma occur in temporal lobe. Spinal cord ganglioglioma is a very rare entity. We report two cases of cervico-dorsal region ganglioglioma, who underwent complete surgical excision. In the postoperative period they had transient deterioration of their neurological status that gradually recovered with follow-up.

Foramen magnum tumors: a series of 30 cases

BACKGROUND AND AIMS

Foramen magnum tumors, especially those located ventrally, are surgically challenging. We studied clinical and surgical details of extramedullary tumors located in the region of the foramen magnum.

MATERIAL AND METHODS

A series of 30 cases of extramedullary tumors at the foramen magnum, operated over a period of 8 years is presented.

RESULTS

There were 10 neurofibromas, 8 meningiomas, 6 chordomas, 2 tuberculomas and 4 miscellaneous tumors. The clinical profile consisted of sensory symptoms in all the patients, quadriparesis in 24, lower cranial nerve affection in 8 and sphincter disturbances in 6 patients. The surgical approaches consisted of an extreme lateral approach in 10, a posterior or posterolateral approach in 18 and a per-oral route in 2 cases. Total excision of the tumor was performed in 24 and a subtotal excision of the tumor was done in 6 cases. Two patients died, one due to meningitis and the other due to chest infection. Eight other patients had complications like CSF leak, meningitis, pseudomeningocele, laryngeal edema, and transient worsening of neurological deficits.

CONCLUSIONS

Foramen magnum tumors have long been regarded as difficult lesions both in terms of diagnosis and management. However, with the availability of MR imaging, newer surgical techniques and skull basal exposures, the excision of these lesions is becoming easier and safer.

Large cystic fibrous dysplasia of the temporal bone: case report and review of literature

Fibrous dysplasia is an uncommon benign disorder of unknown aetiology. It most likely represents a disorder of normal bone development. As it may occasionally involve the temporal bone, and encroach on the middle cranial fossa, it is of interest to the neurosurgeon. Fibrous dysplasia of the cystic variety is very uncommon. We report a case of a large cystic fibrous dysplasia involving predominantly the squamous temporal bone. The radiology and histology are discussed, and its differentiation from other lesions.

Giant vertebrobasilar junction aneurysms: unusual cases

Giant vertebrobasilar (VB) junction aneurysms are uncommon aneurysms, especially those associated with multiple aneurysms of the posterior circulation. We report two cases, one with a small and a giant aneurysm of the VB junction which were surgically clipped; and the other with a small left anterior inferior cerebellar artery (AICA) aneurysm which resolved spontaneously. The patient, however, developed a de-novo giant VB junction aneurysm, which was detected on a follow-up angiogram. This aneurysm was treated by surgical clipping. The clinical features, angiographic considerations and surgical treatment of such rare conditions are discussed and the relevant literature reviewed.

Fenestration of the posterior communicating artery

A 21-year-old male presented with sudden onset of right-sided third nerve paresis. Angiogram showed a fenestrated posterior communication artery on the right side and no other vascular anomalies. There was no other lesion that could suggest a cause for the third nerve weakness. Fenestration of the posterior communicating artery has not been reported till date. The case is discussed and the literature on the subject is reviewed.

Subarachnoid hemorrhage and intracereebral hematoma following lumboperitoneal shunt for pseudotumor cerebri: a rare complication

Placement of lumboperitoneal (LP) shunt as a surgical treatment for benign intracranial hypertension (BIH) is generally a safe procedure, with complications like mechanical failure, overdrainage and infections. Subarachnoid hemorrhage and intracerebral hematoma were seen after lumboperitoneal shunt in a patient having BIH. These complications were the cause of the patient's deterioration. After removal of the hematoma and performing a decompressive procedure, patient's neurological condition improved. The clinical features, investigations and clinical course are described and the literature reviewed.

Chronic subdural haematoma and the enigmatic eosinophil

The membranes from 50 cases of chronic subdural haematomas were examined histologically and correlated with the duration of the lesion. Cases were divided into three groups based on duration from time of trauma and/or onset of clinical symptoms to date of surgery - Group I: 1 to 30 days, Group II: 31 to 90 days and Group III: >90 days. Infiltration with eosinophils was observed in the vascularised and hyalinised granulation tissue of the subdural membrane in 30 of the 50 cases (60%). There was a trend to correlation both of the frequency and the extent of eosinophilic infiltration with duration of haematoma. Thus, eosinophils were encountered in about half the cases with duration up to 3 months which increased to 80% in cases with duration more than 3 months. The extent of eosinophilic infiltration (mild, moderate or severe) also appeared to correlate with duration of haematoma in that mild infiltration was more common in Group I cases while moderate to severe infiltration were more frequently observed in Group II and III cases. No correlation was observed of the eosinophilic infiltrate with age and sex of the patients or with presence of other cellular inflammatory components of the membrane. Interestingly, a finding hitherto unreported in English literature was the demonstration of mast cells in 7 of 16 membranes (44%) which had been stained using toluidine blue. It is possible that the eosinophils appear at this unusual site due to chemotactic stimulus abetted by these mast cells as well as lymphocytes and haemosiderin pigment. The eosinophils may have an important role in the repair and healing process of these membranes.

Obstetric brachial plexus palsy: a clinical and electrophysiologic evaluation

BACKGROUND

Obstetrical brachial plexus palsy (OBPP) occurs as sequelae of birth-related trauma, antenatal and parturition related complications. It is associated with varying degrees of functional disability. Electrodiagnostic studies (EDS) are an adjunctive tool and help to localise and prognosticate the outcome of OBPP.

METHODS

Fourteen children, presenting with OBPP to the Clinical Neurophysiology Lab, were analyzed. Details of birth history were obtained, and EDS were performed to characterize the lesion.

RESULTS

The age ranged from one month to one year. Ten had unilateral and four bilateral brachial palsy. On EDS, five had pan-plexus, six predominantly upper plexus and three lower plexus involvement. A poor re-innervation pattern on EMG correlated with inadequate recovery.

CONCLUSION

OBPP, a condition associated with considerable disability, needs to be prevented. Electrodiagnostic studies are a useful adjunctive tool for characterizing the site of injury and prognostication.