Long-term outcome and prognostic factors of intramedullary spinal hemangioblastomas.

Spinal hemangioblastomas constitute 1.6-5.8% of all spinal cord tumors. Microsurgical excision of these tumors is challenging. The purpose of this study is to analyze the neurological improvement and long-term functional outcome of spinal hemangioblastomas. This retrospective study included 15 patients who underwent surgery for intramedullary spinal hemangioblastoma at the Department of Neurosurgery of Sri Chitra Tirunal Institute for Medical Sciences and Technology from January 2001 to June 2014. Eight patients (53%) were diagnosed to have von Hippel-Lindau (vHL) disease. Eight (53%) of them were females, and seven were males (47%). Mean age was 33.8 years (16-55 years). Duration of illness ranged from 2 weeks to 4 years, and average duration was 10.5 months. Most common symptom was motor weakness followed by sensory disturbances, pain, and bladder incontinence. Six (85.7%) sporadic spinal hemangioblastomas were in McCormick grade I; whereas, 7 (87.5%) of vHL spinal hemangioblastomas were in grade II or above. In the immediate postoperative period, three patients noticed improvement in their motor weakness. Six patients (40%) experienced deterioration of preoperative neurological status in the immediate postoperative period. Three of them were sporadic tumors, and others had vHL syndrome. Favorable long-term outcome was achieved in 80% of cases. Though neurological deterioration is common after surgical resection of spinal hemangioblastomas, majority of them are reversible. Long-term functional outcome is favorable with minimal postoperative morbidities. Both sporadic- and vHL-associated tumors share common clinical and radiological features, and neurological outcome is equally good in both.

Analysis of Prognostic Factors, Extent of Resection, and Long-Term Outcome of Craniopharyngioma in Adults and Children.

Introduction: Surgical management of craniopharyngioma is debatable and still lacks clear guidelines. Long-term complications are attributed to radical resection of the tumor. Extent of resection may not be the only factor which determines the functional outcome, because studies have reported hypothalamic and visual morbidities even with conservative resection. In this article, we analyze the extent of resection, long-term outcome, and various prognostic factors in adults and children. Materials and Methods: Newly diagnosed cases of craniopharyngioma operated between 2001 and 2013 were reviewed retrospectively. PFS and OS were calculated. Predictors of various outcome parameters were analyzed. Results: Of 140 patients, 41% were children and 59% were adults. Postoperatively, vision has improved in 63% and worsened in 12%. GTR was achieved in 66%. The median follow-up was 67 months. PFS at 5 and 10 years was 95% and 41.5%, respectively. OS at 5 and 10 years was 92.6% and 89.5%, respectively. Symptoms of raised ICP and hypothalamic involvement, extensive calcifications, tumor size >5 cm, and multi-compartmental tumors were associated with presence of residual tumor. Regression analysis showed symptoms of hypothalamic involvement, size of the tumor > 5 cm, and hydrocephalus predicted postoperative hypothalamic morbidities. No significant difference was found in postoperative visual, endocrinological, hypothalamic, and functional outcomes between GTR and STR. Conclusion: Conservative resection should be carried out in patients with preoperative hypothalamic symptoms and imaging evidence of extensive hypothalamic involvement. Size of the tumor and invasiveness are the other factors should be considered before radical excision of craniopharyngiomas.

Isolated Infarction of the Splenium: A Rare Presentation of Mild Head Injury.

Posttraumatic cerebral infarction (PTCI) is a devastating complication of traumatic brain injury. It is usually seen in patients with moderate-to-severe head injury with a reported incidence of 1.9%-10.4%. Brain shift associated with the traumatic intracranial space-occupying lesions with or without severe cerebral edema is the most common mechanism underlying the PTCI. Without associated direct vascular injury, isolated PTCI is very rare after mild head injury. Such cases of PTCI following mild head injury have been reported in children in whom they usually affect the gangliocapsular region supplied by the lenticulostriate arteries. Such infarcts in adults are extremely rare. Although the exact pathogenesis is not clear, vasospasm or shearing-associated intimal tear is proposed to be the cause for this infarct. Other common causes of cerebral infarction should be ruled out before making such a diagnosis. Unlike PTCI associated with a severe head injury, cerebral infarction following mild head injury is expected to have a better neurological outcome.

Adult craniopharyngioma: The role of extent of resection in tumor recurrence and long-term functional outcome.

OBJECTIVE: The optimal therapeutic approach to craniopharyngioma has not been established conclusively. The surgical outcome following radical excision and conservative resection with adjuvant radiotherapy are comparable or even better with the later in pediatric or mixed populations. This study is aimed at reviewing the role of extent of resection in local tumor control and long-term outcome in adults with craniopharyngioma. PATIENTS AND METHODS: Ninety-five adults operated between 2001 and 2013 were included. Progression-free survival (PFS) and overall survival (OS) were calculated. Predictors of various outcome parameters were analyzed. RESULTS: The predominant presenting symptom was visual impairment (78 %) followed by symptoms of hypothalamic involvement (29 %). Total and subtotal excisions (TE, STE) were achieved in 63 %, and 47 % of patients, respectively. Vision improved in 62 % of patients in the early postoperative period. Thirteen patients (14 %) experienced vision deterioration postoperatively. On multivariate analysis, tumor >3 cm and optic atrophy predicted poor visual outcome. Hormonal replacement for hypopituitarism was required in 83 % during follow-up. Diabetes insipidus was seen in 73 %. Imaging evidence of 3rd ventricular floor destruction by tumor emerged as an independent predictor of postoperative hypothalamic morbidities. The recurrence rate following TE and STE was 11.6 % and 72 %, respectively. Unlike radical excision, PFS following STE was significantly shorter (p- 0.02). TE was not associated with increased visual impairment or hypothalamic-pituitary dysfunction postoperatively as compared to STE. Most of the patients (85 %) were independent and able to return to the premorbid occupation. CONCLUSION: Subtotal resection provides equally good long-term visual, endocrinological, and hypothalamic outcomes as radical surgery. When used with adjuvant radiotherapy, it also gives a better local control of the tumor. Hence, subtotal resection with adjuvant radiotherapy should be considered as an effective alternative strategy to radical excision.

Isolated Orbital Roof Fracture: Can It Be Catastrophic?

Orbital encephalocele is a rare catastrophic complication of orbital roof fractures. Early diagnosis of this posttraumatic orbital encephalocele is very crucial because this condition if untreated leads to rapid loss of vision. Whenever displaced orbital roof fracture is identified in a head injury patient, an orbital encephalocele should be suspected. Although magnetic resonance imaging is the investigation of choice, computed tomography of orbit with thin axial and coronal sequences often gives the diagnosis. Frontobasal approach is the most commonly used surgical approach. Supra-transorbital approach is a minimally invasive alternative. Good results with regard to the orbital symptoms can be expected.