Long-term hormonal and imaging outcomes of adjunctive gamma knife radiosurgery in non-functioning pituitary adenomas: a single center experience.

PURPOSE: Gamma Knife Radiosurgery(GKRS) is an established modality for treatment of non-functioning pituitary adenomas(NFPA). The objective of the study was to assess long-term hormonal and imaging outcomes after adjunctive GKRS in patients with NFPA. METHODS: A retrospective review of records of 109 patients with NFPA, from 1996 to 2020, who received adjunctive GKRS, was performed. Patients who had received GKRS as the primary modality of treatment for NFPA were not included. RESULTS: Sixty-three (57.8%) patients were available for follow up at our institute. The median follow-up period was 47 months (range, 6-260). At a median time of 38 months (range, 8-97), 25 (39.7%) patients developed ≥ 1 new pituitary hormone deficiency. Median time to cortisol deficiency was 38 months (range, 8-55), thyroid hormone deficiency was 45.5 months (range, 12-97) and gonadotropin deficiency was 45 months (range, 21-75). The actuarial risk of developing a new pituitary hormone deficit at 1, 3, 5, 7, and 10 years was 2.5%, 11%, 26.3%, 28% and 29.7%, respectively. Adenoma size decreased in 36 (57.1%) patients, remained unchanged in 19 (30.2%) patients, and increased in 8 (12.7%) patients. Overall tumor control rate was 87.3%. Endocrinopathy-Free Survival was 47.1%, and tumor Progression-Free Survival was 93.3%, at 5 years. Five (4.6%) patients required additional treatment after GKRS. One (1.6%) patient each had worsening of headache, optic atrophy and cerebellar infarct after GKRS therapy. CONCLUSION: GKRS offers a safe adjunctive treatment modality, with satisfactory long-term preservation of hormone functions and a high rate of tumor control, in patients with NFPA.

Wernike's Encephalopathy as a Part of Refeeding Syndrome.

Cases have been reported about refeeding syndrome after bariatric surgery for obesity, in head and neck cancer patients, in patients with anorexia nervosa, hyperemesis gravidarum, in persons on hunger strike, malnourished alcoholic persons and persons doing religious fasting. Refeeding after prolonged fasting can cause severe morbidity and even mortality, if not done properly. Depletion of intracellular electrolytes, depletion of nutrients and vitamins, decreased BMR, decreased renal functions, decreased insulin, decreased GI functions all contribute to it, once you start refeeding. It takes sometime to regain the original functions by the organs and mismatch between supply and increased demand after refeeding can cause havoc. Here we report the case of a person, who did water only fasting for 51 days and developed refeeding syndrome and Wernike's encephalopathy four days after starting liquid diet.

Radiation-induced brachial plexus neuropathy: A review.

Radiation-induced brachial plexus neuropathy (RIBPN) is an uncommon problem. It is a delayed nontraumatic brachial plexus neuropathy following radiation treatment for carcinomas in the region of neck, axilla, and chest wall. The incidence is more commonly reported following radiation treatment for carcinoma of breast. The neurological features are characterized by severe neurogenic pain with progressive sensory-motor deficits in the affected upper limb. The incidence has increased following improved survival rate of patients with carcinomas of neck, axilla, and chest wall. The diagnosis of RIBPN is often confused with recurrence of the tumor in the neck and axilla. The management options are limited, and external neurolysis of the involved brachial plexus with excision of the perineural scar tissue is recommended in patients with severe clinical manifestations. We review our experience in the management of RIBPN from 2004 to 2017 and highlight the features of the 11 patients with this disorder whom we encountered during this period. The relevant clinical findings, natural history, pathophysiology, radiological characteristics, and various management options are briefly discussed.

Injection-related iatrogenic peripheral nerve injuries: Surgical experience of 354 operated cases.

OBJECTIVE: A retrospective analysis of surgically treated 354 cases of injection-related iatrogenic peripheral nerve injuries was performed. The purpose of this clinical study was to present our experience in the management of various types of injection-related peripheral nerve injuries and discuss various issues that are associated with this subset of peripheral nerve injuries. METHODS: Over a 17-year period, 354 cases of injection-related iatrogenic peripheral nerve injuries were managed surgically at the Department of Neurosurgery at P.D. Hinduja Hospital and Seth G S Medical College, Mumbai. In our series, the injection-related iatrogenic nerve injuries were following intramuscular injections, brachial nerves block procedures, subclavian and jugular venous cannulation procedures for central line placements, and routine intravenous injections in the peripheral veins of the limbs. The age of the patients ranged from 5 years to 65 years. Pain, paresthesia, and sensory-motor deficits were the common presenting features in our series. The operative procedures performed in our series were external neurolysis and excision of neuroma/contused portion of the nerve and sural nerve cable grafting. The follow-up ranged from 6 months to 84 months. There were no major intraoperative complications in our series. RESULTS: In our series, functional improvement (power grade 3 or above) was noted in 190 (53.7%) patients following surgical intervention. In 164 (46.3%) patients, there was either a non-functional status or no recovery. Neurological deterioration in the form of motor weakness was noted in 9 (2.5%) patients in our series after the surgery. The best results (90.1%) were noted with radial nerve repair following surgical intervention. CONCLUSION: Injection-related iatrogenic nerve injuries are not an uncommon problem. Surgery should be the preferred treatment option when the injured nerve fails to recover following the insult. The results are rewarding in a significant percentage of patients following timely intervention. The problem of litigation attached with this type of injury is also highlighted.

Exploring of greater yam (Dioscorea alata L.) genotypes through biochemical screening for better cultivation in south Gujarat zone of India.

Fifteen different genotypes of greater yam (Dioscorea alata) NGY-1, NGY-2, NGY-3, NGY-4, NGY-5, NGY-6, NGY-7, NGY-8, NGY-9, NGY-10, NGY-11, NGY-12, NGY-13, NGY-14 and Da-199 were procured from different places of south Gujarat, like Valsad, Navsari, Surat and Anand. Among the biochemical parameters total carbohydrate ranged between 51.87 and 87.85% from different genotypes, starch ranged from 47 to 80.67%, crude fat ranged from 0.6 to 2.32%, crude fibre ranged between 1.10 and 4.09%, anthocyanin content of genotypes ranged from 1.01 to 3.25 mg/g, beta-carotene content ranged between 0.97 and 1.88 µg/g. The antinutrients namely Diosgenin and Tannin ranged from 0.28 to 0.93% and 0.923 mg/100 g to 2.447 mg/100 g, respectively. RAPD analysis was also done by the help of 18 RAPD markers: OPA1, OPA2, OPA3, OPA13, OPB1, OPB6, OPB7, OPM1, OPM2, OPM4, OPM7, OPM11, OPM12, OPM13, OPM15, OPM16, OPM17 and OPM19 from which an average of 9.7 loci were detected with an average of 4.72 polymorphic loci which is 48.65% polymorphism per loci and 48.70% average polymorphism. From the overall study, it can be conferred that the study revealed highest carbohydrate content in NGY-3 (87.85%), fat (2.32%) and crude fiber content (4.09%) in NGY-11, ß-carotene in NGY-7 (1.88 µg/g), anthocyanin in NGY-4(3.25 mg/g). Lowest tannin (0.923 mg/100 g) and diosgenin (0.28%) was found in NGY-6, and NGY-7 respectively. For each of the biochemical parameters, the varieties with the optimum values may be cultivated. As the molecular studies revealed NGY-2 and NGY-3 have 96% similarities, they may be the duplicate of the same genotypes which can be studied further for better germplasm conservation.

Successful Management of Elizabethkingia meningoseptica Meningitis with Intraventricular Vancomycin.

Elizabethkingia meningoseptica, formerly Chryseobacterium meningosepticum usually causes neonatal meningitis and is a rare cause of nosocomial meningitis in adults. E. meningoseptica is resistant to most antibiotics, and the use of inactive drugs as empirical therapy may contribute to poor outcome in many patients. Vancomycin, alone or in combination with rifampicin, has been successful in the treatment of meningitis in infants1. We present a case of E. meningoseptica meningitis in an adult who was treated initially with intravenous vancomycin and oral rifampicin, but did not respond to the treatment. Thereafter, intraventricular vancomycin was added which resulted in good treatment response.

Core outcomes in nerve surgery: development of a core outcome set for brachial plexus and upper extremity nerve injuries.

OBJECTIVE: When considering traumatic brachial plexus and upper extremity nerve injuries, iatrogenic nerve injuries, and nontraumatic nerve injuries, brachial plexus and upper extremity nerve injuries are commonly encountered in clinical practice. Despite this, data synthesis and comparison of available studies are difficult. This is at least in part due to the lack of standardization in reporting and a lack of a core outcome set (COS). Thus, there is a need for a COS for adult brachial plexus and upper extremity nerve injuries (COS-BPUE). The objective of this study was to develop a COS-BPUE using a modified Delphi approach. METHODS: A 5-stage approach was used to develop the COS-BPUE: 1) consortium development, 2) literature review to identify potential outcome measures, 3) Delphi survey to develop consensus on outcomes for inclusion, 4) Delphi survey to develop definitions, and 5) consensus meeting to finalize the COS and definitions. The study followed the Core Outcome Set-STAndards for Development (COS-STAD) recommendations. RESULTS: The Core Outcomes in Nerve Surgery (COINS) Consortium comprised 23 participants, all neurological surgeons, representing 13 countries. The final COS-BPUE consisted of 36 data points/outcomes covering demographic, diagnostic, patient-reported outcome, motor/sensory outcome, and complication domains. Appropriate instruments, methods of testing, and definitions were set. The consensus minimum duration of follow-up was 24 months, with the consensus optimal time points for assessment being preoperatively and 3, 6, 12, and 24 months postoperatively. CONCLUSIONS: The COINS Consortium developed a consensus COS and provided definitions, methods of implementation, and time points for assessment. The COS-BPUE should serve as a minimum set of data that should be collected in all future neurosurgical studies on adult brachial plexus and upper extremity nerve injuries. Incorporation of this COS should help improve consistency in reporting, data synthesis, and comparability, and should minimize outcome reporting bias.

Post covid cerebral phaeohyphomycosis by Rhinocladiella mackenziei: An unusual association.

Cerebral phaeohyphomycosis (CP) is a rare but a highly morbid fungal infection of the central nervous system caused by the fungi belonging to the order Chaetothyriales, which includes Cladophialophora bantiana, Exophiala dermatitidis, Rhinocladiella mackenziei (RM) etc. This disease is associated with poor clinical outcomes, with reported mortality of over 80%. We present the case of a 65-year gentleman who developed CP secondary to RM infection following COVID-19 and the associated challenges in his medical and surgical management.

Ceftazidime-resistant Burkholderia pseudomallei masquerading as isolated atypical neuromelioidosis.

A middle-aged recently diagnosed uncontrolled diabetic from Mumbai, India presented with fever and headache for 8 weeks. Two weeks prior to his symptoms, he travelled to Lonavala during the monsoons and gave history of indoor swimming in a chlorinated pool. Investigations showed isolated neurological involvement with multiple brain abscesses. Abscess cultures grew a non-lactose fermenter. Automated systems failed to identify it. After assessment of his background history and detailed microbiological analysis of the organism, specific investigations were requested which confirmed the suspected diagnosis of melioidosis. We report an unusual presentation of ceftazidime-resistant Burkholderia pseumodmallei as isolated neuromelioidosis with brain abscesses.

Segmental Schwannomatosis of the Lower Extremity - A Case Series.

Segmental schwannomatosis involving a nerve in single limb is uncommon. Schwannomatosis is used to describe a distinct clinicopathological disease of multiple schwannomas without manifestations of neurofibromatosis, and it is termed segmental when a single extremity is involved. Surgery is indicated when there is progressive clinical deterioration or progressive increase in size of the tumors. We present a case series of segmental schwannomatosis involving the lower limb.

Differences in management and treatment of traumatic adult pan brachial plexus injuries: a global perspective regarding continental variations.

An expert opinion study was designed to query five countries and six brachial plexus surgeons regarding the demographics, mechanisms of injury, evaluation, timing of surgery, reconstructive strategies and controversies in adult traumatic pan brachial plexus injuries. Variations in assessing outcomes, management of neuropathic pain and future considerations were elucidated. Clear differences in regional demographics, mechanisms of injury, patient evaluation and treatment strategies were identified. The role of phrenic nerve and contralateral C7 transfer, acute use of free functioning muscle transfers, root reimplantation and amputation/myoelectric prosthetic fitting were regional/surgeon dependent. Comparison of outcomes across regions requires an understanding of the regional nuances of patient demographics, injury mechanisms, preferred reconstructive strategies and how outcomes are measured. Future studies are required to allow accurate regional comparisons.

Analysis of the Long-Term Outcome in Open Carpal Tunnel Release Surgeries with and without External Neurolysis of Median Nerve, Using Boston Carpal Tunnel Questionnaire (BCTQ)-Hindi Version.

Background The effectiveness of open carpal tunnel release (OCTR) in treating carpal tunnel syndrome (CTS) is well known. However, the role of ancillary external neurolysis of the median nerve is not well-documented. The Boston carpal tunnel questionnaire (BCTQ) is a commonly used disease-specific outcome instrument for CTS, which is validated across major languages of the world. No such validated Hindi version of BCTQ exists. Objectives To analyze and compare the long-term outcome in patients who underwent OCTR alone and OCTR with external neurolysis of the median nerve, using BCTQ-Hindi version, while checking its validity. Materials and Methods A retrospective, cross-sectional study was conducted at a tertiary care institute. The BCTQ was translated into Hindi language by a language expert. Eighty-four consecutive patients who underwent either unilateral/bilateral OCTR, with or without external neurolysis of the median nerve, between 2009 and 2019 were included in the study. Outcome analysis was done using BCTQ-Hindi version and patient satisfaction scoring. BCTQ-Hindi version was examined for statistical validity. Subgroup analysis of the outcome based on surgical technique (OCTR vs. OCTR with external neurolysis) used was carried out. Results Response rate was 80.9%. Total hands evaluated were 108. BCTQ-Hindi version showed statistical validity. Overall symptom severity score (SSS) and functional severity score (FSS) were 1.14 ± 0.4 and 1.12 ± 0.35, respectively. Subgroup analysis of outcome revealed statistically significant results in favor of OCTR with external neurolysis of the median nerve. Conclusions BCTQ-Hindi version is statistically validated. OCTR with external neurolysis of the median nerve is a promising avenue in surgical management of CTS. Further prospective studies are warranted.

Retrospective analysis of peripheral nerve sheath tumors of the second cervical nerve root in 60 surgically treated patients.

OBJECT: This study is a retrospective analysis of 60 surgically treated patients with 64 peripheral nerve sheath tumors (PNSTs) at the second cervical (C-2) nerve root. The anatomical subtleties of these tumors and their implications for surgical strategy when compared with other spinal PNSTs and other tumors in the foramen magnum region are reviewed. METHODS: Sixty patients with C-2 PNSTs treated surgically in the Department of Neurosurgery at King Edward VII Memorial Hospital and Seth Gordhandas Sunderdas Medical College between 1992 and 2006 were studied. All patients underwent magnetic resonance imaging. Tumors were divided into 3 groups depending on their anatomical location identified during surgery. Those tumors located within or extending into the spinal dural tube were called Type A, those located within the dural tube of the C-2 ganglion were labeled as Type B, and tumors extending laterally into the paraspinal region were labeled as Type C. Follow-up durations ranged from 6 months to 15 years (mean 64 months). RESULTS: There were 38 male and 22 female patients in the study, who ranged in age from 6 to 62 years (mean 28 years). Nine patients had clinical features indicative of neurofibromatosis (NF). The mean duration of symptoms at the time of presentation was 27 months (range 4 days-5 years). Two patients had no specific symptoms related to the C-2 PNST, 6 patients had only local symptoms such as neck pain or stiffness, and 52 patients had symptoms of varying degrees of myelopathy. There were 5 solely Type A tumors, 7 Type A + B tumors, 31 Type B tumors, and 21 Type B + C tumors. All Type A, A + B, and B tumors were totally resected. Seven of 21 Type B + C tumors were partially resected, and the remainder were completely resected. All patients postoperatively reported varying improvement in their preoperative symptoms. Except for patients with NF who were disabled by other tumors, the rest of the patients resumed their normal life style. There have been no cases of symptomatic tumor recurrence. CONCLUSIONS: The majority of PNSTs located at the C-2 level in these patients probably arose from the large C-2 ganglion and are limited within the dural confines or are interdural in location. In contrast to other spinal PNSTs, the location of C-2 PNSTs is in most cases posterior to the lateral mass of the atlas and axis and the atlantoaxial joint and is exposed to the posterior without any bone cover. Radical tumor resection is safe, resolution of clinical symptoms is rapid, and recurrence rates are extremely low. In a selected number of cases, bone work for tumor exposure and resection can be entirely avoided.

A rare case of bilateral central subluxation of the hip joint with associated bilateral quadrilateral plate fracture in an elderly male due to seizure activity.

Musculoskeletal injuries such as dislocation of the shoulder and hip joints and fractures of the femoral neck are known complications of seizures. Bilateral central subluxation of the hip joint with associated bilateral quadrilateral plate fracture is a rare entity and is prone to delayed diagnosis, even more so in patients who experience post-seizure disorientation. The authors report the case of a 74-year-old male patient with bilateral central subluxation of the hip joint with associated bilateral quadrilateral plate fracture due to seizure activity. Bilateral open reconstruction and fixation of the quadrilateral plate with a 3.5-mm pre-bent reconstruction plate reinforced with 3.5-mm pelvic brim reconstruction plate was performed. In conclusion, this case is an example of rare bilateral quadrilateral plate fracture caused due to seizure activity, a fracture for which a high level of suspicion should be kept in mind while evaluating the patient post-seizure episode.

Lesões musculoesqueléticas, tais como luxação das articulações do ombro e quadril e fraturas do colo do fêmur, são complicações conhecidas de convulsões. A subluxação central bilateral da articulação do quadril associada a fratura bilateral da alâmina quadrilátera do acetábulo é uma entidade rara e propensa ao diagnóstico tardio, ainda mais em pacientes que experimentam desorientação pós-convulsão. Os autores relatam o caso de um paciente masculino de 74 anos de idade com subluxação central bilateral da articulação do quadril associada a fratura bilateral da lâmina quadrilátera decorrente de atividade convulsiva. Foi feita reconstrução bilateral aberta e a lâmina quadrilátera foi fixada com uma placa de reconstrução pré-dobrada de 3.5 mm, reforçada com uma placa de reconstrução da borda pélvica de 3,5 mm. Conclui-se que este caso é um raro exemplo de fratura bilateral das lâminas quadriláteras causada pela atividade convulsiva. Os profissionais de saúde devem manter um alto nível de suspeita para esse tipo de fratura ao avaliar pacientes após um episódio convulsivo.

Cranial migration of complete ventriculo-peritoneal shunt assembly.

A 10-month-old male child with severe congenital hydrocephalus due to aqueduct stenosis presented with cranial migration of the entire ventriculo-peritoneal (VP) shunt. The complete shunt assembly, including the shunt chamber, was noted in the dilated ventricles. The migrated shunt was left in situ. A VP shunt was performed on the opposite side. The complete intraventricular migration of a VP shunt is a rare complication. This complication may be avoided by firm anchoring of the connector sites to the periosteum, and avoidance of large burr holes and dural openings. The possible mechanisms of such an event and the relevant literature are discussed.

The Surgical Management of Symptomatic Benign Peripheral Nerve Sheath Tumors of the Neck and Extremities: An Experience of 442 Cases.

BACKGROUND: The occurrence of benign peripheral nerve sheath tumors (PNSTs) is not uncommon. The surgical excision of symptomatic benign PNSTs along with preservation of the affected nerve and its function is an ideal treatment option. OBJECTIVE: To analyze the outcome with respect to morbidity, extent of resection, and recurrence, and to review and compare our results with those reported in literature. METHODS: A retrospective review of clinical and radiological findings of 442 patients with benign PNSTs involving the neck and extremities treated surgically from 2000 to 2014 was performed. RESULTS: In our series, benign PNSTs involved the extremities in 290 (65.6%) patients and the brachial plexus in 146 (33%) patients, and 6 (1.4%) patients had tumors of the extracranial portion of the vagus and hypoglossal nerves in the neck. The mean age of patients was 38 yr. The presenting features were painful mass and paresthesia. Preoperative motor weakness in the extremity was noted in 15.6% of patients. The common nerves involved by the tumors were the ulnar nerve (15.8%), sciatic nerve (12.7%), and upper cervical roots (11.5%). The excision was total in 81.2%, gross total (>90%) in 17.9%, and subtotal (>50%) in 0.9% patients. In 17.6% of patients, there was severe postoperative neurogenic pain. In 28 (6.3%) patients, a new motor deficit was noted following surgery. Recurrence was seen in 2 patients in our series. The mean follow-up was 30.2 mo. CONCLUSION: Benign PNSTs have excellent clinical outcome, and the goal for surgical treatment is total to gross total excision of the tumor with neural preservation.