Expert panel recommendations for topical hemostatic agent use in varied bleeding sites and situations during neuro-spine surgeries

Intraoperative bleeding poses a substantial challenge, particularly in neuro-spine surgeries leading to complications such as hematomas, infections, and hemodynamic instability. Despite their proven efficacy, use of topical hemostatic agents (THAs) lacks comprehensive published literature and guidelines particularly in the Indian setting. The present study provides the first-ever Indian expert panel recommendations for effective adjunct THA use in different intraoperative bleeding sites and situations in neuro-spine surgeries. A comprehensive approach, encompassing a literature review, followed by experience sharing in a meeting using a survey helped integrate expert opinions in the form of practical algorithms to guide THA selection. Our survey results revealed a strong inclination towards specific THAs, flowable gelatin + thrombin being choice of THA for difficult to access and problematic bleeding situations during tumor removal/resection, transsphenoidal hypophysectomy and skull-based procedures. Both oxidized regenerated cellulose (ORC)/Fibrillar and flowable gelatin + thrombin were recommended for continuous oozing. ORC/Fibrillar was preferred for arteriovenous and cavernous malformations. This expert-panel guidance on THA use aims to optimize hemostat use practices and improve surgical outcomes in neuro-spine surgery.

Prospective glioma grading using single-dose dynamic contrast-enhanced perfusion MRI

AIM

To evaluate the sensitivity and specificity of single-dose dynamic contrast-enhanced (DCE) perfusion magnetic resonance imaging (MRI) in prospective evaluation of glioma grading and to correlate the relative cerebral blood volume (rCBV) values with mitotic and ki-67 indexes obtained at histopathology.

MATERIALS AND METHODS

A total of 53 histologically proven patients with glioma were included in this study. DCE-MRI perfusion with a single dose of contrast medium was included in brain tumour protocol and prospective grading of glioma into low and high grade was done based on a previously reported rCBV cut-off value of 3. Tumours with rCBV ≥ 3 were considered to be high grade and rCBV < 3 were considered to be low grade. The sensitivity and specificity of the cut-off value were estimated. Ki-67 and mitotic indexes were also obtained on histopathological analysis along with histological grading.

RESULTS

Based on pre-defined rCBV cut-off values, prospective grading of low- and high-grade glioma was achieved with a sensitivity and specificity of 97.22% and 100%, respectively. Significant correlation was found between the mitotic/ki-67 indexes and rCBV values when data for high- and low-grade tumours was combined.

CONCLUSION

DCE-MRI performed with a single dose of contrast medium is as effective as a protocol with a double-dose of contrast medium for glioma grading using 3 T MRI and could be added to the routine evaluation protocol of brain tumours.

Coil embolization of very small (2 mm or smaller) berry aneurysms: feasibility and technical issues

BACKGROUND AND PURPOSE

The very small size of cerebral aneurysms is considered to be one of the limitations for endovascular treatment, with a high risk for intraoperative rupture. We report on treatment of very small saccular ruptured cerebral aneurysms by coil embolization. All the cases were of 2-mm aneurysms with at least 1 of the dimensions being less than 2 mm.

MATERIALS AND METHODS

We performed retrospective analysis of 7 consecutive cases of very small aneurysms treated by coil embolization in our institution between July 2006 and April 2008.

RESULTS

3D rotational angiography (3DRA) was found to be most accurate in the detection of these aneurysms; in 2 cases, 3DRA revealed the aneurysms after results on digital subtraction angiography (DSA) were considered to be negative. Coil embolization was successfully performed in 6 cases, whereas in 1 case, spontaneous thrombosis occurred after microcatheter placement. Complete (n = 5) or near complete (n = 2) immediate occlusion was seen. A single soft coil was used in all cases with the shortest available length. Balloon assistance was used in 3 cases. Although minimal coil projection in the parent vessel was seen in 3 cases, no untoward clinical complication was seen. Follow-up DSA and MR angiography in 4 patients demonstrated persistent occlusion (n = 3) or progressive thrombosis (n = 1) of the aneurysms. All of the patients with available follow-up are independent in day-to-day activities with a modified Rankin Score (mRS) of 0 or 1.

CONCLUSIONS

Coil embolization of very small ruptured cerebral aneurysms is feasible. Careful consideration of the technical issues in treatment of these cases is essential to achieve technical success while avoiding complications.

Use of CT angiography for anatomic localization of arteriovenous malformation Nidal components

We report a case of diffuse arteriovenous malformation (AVM) in basal ganglia and an internal capsule associated with venous aneurysms. The patient was treated by embolization guided by CT angiography to target the basal ganglionic portion of the AVM while sparing the internal capsule. Our case demonstrates that it is possible to obtain good quality intranidal angiograms by using CT angiography, which can be useful for exact localization of the catheterized part of the nidus.

Intraoperative high field magnetic resonance imaging in neurosurgery: Our initial experience with the brain suite

We present our initial experience with the high field (1.5T) intra-operative magnetic resonance imaging, the operating room set-up, our initial cases, the difficulties we faced and how this tool affected a change in the surgical strategy intra-operatively and finally our results. 11 patients were operated on from June 1st to August 1st 2006 of which there were astrocytomas (7), pituitary adenoma (1), craniopharyngioma (1) and meningiomas (2) Localization and lesion targeting were accurate, intra-operative imaging helped to assess the resection volumes, enable corrections for brain shift, perform further tumor resection at the same sitting and help preserve eloquent cortical areas. Gliomas formed 63.6% of the tumors operated on and in 71.4% of these, our surgical strategy changed intra-operatively. Meningiomas formed 9.1% of the tumors operated and image guidance enabled a minimally invasive approach, although no change in our surgical plan was required. One pituitary adenoma and a craniopharyngioma were also operated on with good outcome.

Umbilical CSF fistula: a rare complication of ventriculoperitoneal shunt

An umbilical CSF fistula following a ventriculoperitoneal shunt is an extremely rare complication. We report a 28-year-old man who presented with leak of clear fluid from the umbilicus, one month after a ventriculo-peritoneal shunt revision. Shuntogram revealed communication between umbilicus and abdominal end of the catheter. He was managed successfully with shunt exteriorization, antimeningitic treatment, and later shunt re-insertion.

Spontaneous relapsing and recurring large multiloculated posterior fossa enteric cyst

Intracranial enterogenous cyst is an uncommon entity. We report a case of enterogenous cyst of the posterior fossa situated posterolateral to the brain stem and extending into the left CP angle cistern. Patient had spontaneous regression and recurrence of the cyst. Clinical features and radiological findings are described. Near total excision of the cyst was carried out through the retro mastoid route. Patient made a good postoperative recovery.

Hallervorden spatz disease: MR and pathological findings of a rare case

We describe a child with pathologically proven Hallervorden Spatz disease. He presented with extrapyramidal symptoms and characteristic "eye-of-the-tiger" sign on magnetic resonance imaging. He was given the possible benefit if any of deep brain stimulation with no much improvement. Pathological examination of the brain showed iron deposition in bilateral globus pallidi, spongiform change and neuron axonal degeneration (spheroids).

Frontal intraparenchymal schwannoma: an unusual presentation

CASE REPORT

A 13-year-old male with an 11-year history of a seizure disorder presented with recent onset raised intracranial pressure symptoms and no obvious phakomatosis. CT revealed a heterogeneous, frontal, intra-axial, densely enhancing, solid lesion with intense perilesional oedema and mass effect. Total microsurgical excision resulted in cure. Histopathological examination showed characteristic Antoni A and B areas and occasional Verocay bodies consistent with the diagnosis of an intraparenchymal schwannoma.

DISCUSSION

The authors present a very rare, entirely solid manifestation of this highly uncommon lesion seen mostly in young adults and children with symptoms suggestive of raised intracranial pressure and associated seizure disorders. The possible developmental origins are discussed.

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.

Malignant prolactinoma: is metastasis a must? Clinico-pathologic and immunohistochemical study of a case

Pituitary carcinomas are rare tumors which have been conventionally defined as primary adenohypophyseal tumors with cerebrospinal or extracranial metastases. According to the current criteria even a highly invasive tumor without metastases is not considered as malignant. A case of pituitary adenoma is reported with an unproven site of metastasis but with rapid increase in prolactin levels (35,000 ng/ml), showing extensive invasion on radiology, and pathological and immunohistochemical studies indicating a highly mitotic variety of tumor. On the basis of this case we want to emphasize that extracranial metastasis is not a must to label a pituitary adenoma as a malignant tumor. Such aggressive behavior of the tumor and clinico-pathological course in itself should be sufficient for the tumor to be labeled as malignant.

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.

Split cord malformation: three unusual cases of composite split cord malformation

BACKGROUND

All split cord malformations (SCMs) arise from one basic fault, i.e. the formation of an accessory neurenteric canal between yolk sac and amnion through the midline embryonic disc that splits the notochord and neural plate. Multiple accessory neurenteric canals may lead to two or more noncontiguous SCMs, also known as composite SCM.

CASE HISTORIES

We present here three cases of composite SCM. First, a 2 1/2-year-old boy had type II SCMs at two different levels with normal cord between them. In case 2, a 16-month-old girl revealed a type I SCM at levels L2-3 and a type II SCM at level L5. The third case had a combination of both these types of SCMs at levels L1-3. Only very few cases of composite SCM have been reported in the literature.

CONCLUSIONS

These three cases also support the unified theory proposed by Pang et al.

Early complications following gamma knife radiosurgery for intracranial meningiomas

Object. The purpose of this paper was to assess the early complications, defined as occurring within 1 year, following gamma knife radiosurgery (GKS) for the treatment of intracranial meningiomas.

Methods. Seventy-seven of 306 patients undergoing GKS in the last 2.5 years harbored meningiomas. There were 35 men and 42 women with a mean age of 32.4 years (range 10–80 years). Tumor volume ranged from 0.35 to 28.6 cm3 (mean 7.9 cm3). Gamma knife radiosurgery was the primary therapy in 28 patients and followed surgery in 49 patients. There were 50 basal and 27 nonbasal meningiomas. The most common sites were parasagittal (23 patients) and cerebellopontine angle (14 patients). Ten to 15 Gy was administered to the tumor margins.

Clinical and radiological follow up with a mean duration of 122 months was available in 40 patients. Seizures and increased headache were found in five and four patients, respectively. A temporary worsening of hemiparesis was seen in two patients (both with parasagittal tumors). One patient with a cavernous sinus meningioma developed a herpes labialis eruption. Perilesional edema was demonstrated in nine patients and was symptomatic in six. Six (22%) of the 27 patients with nonbasal tumors had edema (all parasagittal) and four patients were symptomatic. Only three (6%) of the 50 basal meningiomas had edema, and only one patient was symptomatic. The occurence of edema did not correlate with tumor volume, margin or maximum dose, or with radiation received by adjacent brain. A reduction in tumor size was seen in seven patients. In one patient a new recurrent lesion developed adjacent to the previously treated tumor.

Conclusions. Although GKS provides good results for selected patients with meningiomas, caution is required in treating patients with parasagittal tumors as the incidence of perilesional edema is considerable.