Pituitary Apoplexy Following Severe Diabetic Ketoacidosis, With Two Uncommon Complications of Supraventricular Tachycardia and Acute Limb Ischemia in a Patient with Neglected Pituitary Adenoma and Undiagnosed Diabetes Mellitus: A Rare Clinical Association.

Pituitary apoplexy (PA) is a clinical emergency arising from acute ischemia or hemorrhage of the pituitary gland. A small subset of pituitary adenomas present with an apoplectic crisis, with common symptoms being headache, nausea/vomiting, visual impairment, ophthalmoplegia, altered sensorium, panhypopituitarism, etc. Though diabetic ketoacidosis (DKA) is an established complication of uncontrolled diabetes mellitus, its association with PA is extremely rare. Likewise, supraventricular tachycardia (SVT) and acute limb ischemia (ALI) have rare, reported association with DKA. We present one such case of rare associations seen in our clinical practice. A 20-year-old woman was brought to our emergency room with headache, breathlessness, and altered sensorium. Clinical and biochemical evaluation revealed SVT, DKA, and right lower limb ALI. On enquiry, patient was found to be diagnosed with pituitary adenoma 2 years ago and lost to follow-up. PA was detected on neuroimaging and confirmed histopathologically. Possibility of PA presenting as DKA and its sequelae exists.

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.

Efficacy of Gamma Knife Radiosurgery in Refractory Obsessive-Compulsive Disorder: An Indian Experience.

Background Obsessive-compulsive disorder (OCD) is a chronic debilitating psychiatric condition with adverse impact on patient's sociooccupational health. Refractoriness to pharmacotherapy and psychotherapy is not uncommon. Gamma Knife radiosurgery (GKRS) is the comprehensively used and reviewed treatment modality in refractory OCD worldwide. In India, the past two decades of increasing GKRS availability has failed to create the necessary local awareness of its usefulness in refractory OCD. Limited native literature deepens the problem. Objective To analyze our experience with GKRS in refractory OCD, and report the safety and efficacy/long-term outcome in patients using the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS). Materials and Methods A retrospective review of patients receiving GKRS for refractory OCD between 2000 and 2020 was carried out. Case files of the eligible ( n = 9) patients were reviewed for clinical, radiotherapeutic, and outcome data. Additionally, patients were contacted via telephone to enquire about their experiences, and to obtain retroactive consent for GKRS in June 2021. Information obtained was collated, computed, and analyzed. Results Male-to-female sex ratio was 8:1. Mean age at the time of GKRS and mean duration of OCD prior to GKRS was 30.1 ± 9.4 and 10.2 ± 5.8 years, respectively. Mean baseline Y-BOCS score was 29.6 ± 4.7. Our first patient received cingulotomy, while the rest underwent anterior capsulotomy. Median margin dose (50% isodose) was 70 Gy. Also, 23.8 ± 7.7 was the mean Y-BOCS score at the last follow-up (median = 30 months). Overall, 44.4% patients showed full/partial response (≥25% reduction in Y-BOCS score) at the last follow-up. In anterior capsulotomy (eight patients), patients with moderate/severe OCD showed better response (4/5 responders) than those with extreme OCD (0/3 responders). Single case of cingulotomy resulted in no response (<25% reduction in Y-BOCS score). No adverse radiation effects were noted. Also, 55.6% patients gave retroactive consent telephonically. Conclusion GKRS is a safe and effective noninvasive treatment modality for refractory OCD. Ventral anterior capsule is the preferred target. Maximum radiation doses of 120 to 160 Gy are well tolerated. Extremely severe OCD cases fared poorer. Proper awareness about the availability and efficacy of GKRS in refractory OCD is required in India.

Pituitary Apoplexy Following Severe Diabetic Ketoacidosis, with Two Uncommon Complications of Supraventricular Tachycardia and Acute Limb Ischemia, in a Patient with Neglected Pituitary Adenoma and Undiagnosed Diabetes Mellitus: A Rare Clinical Association.

Pituitary apoplexy (PA) is a clinical emergency arising from acute ischemia or hemorrhage of the pituitary gland. A small subset of pituitary adenomas present with an apoplectic crisis, with common symptoms being headache, nausea-vomiting, visual impairment, ophthalmoplegia, altered sensorium, and panhypopituitarism. Though diabetic ketoacidosis (DKA) is an established complication of uncontrolled diabetes mellitus, its association with PA is extremely rare. Likewise, supraventricular tachycardia (SVT) and Acute limb ischemia (ALI) have rare, reported association with DKA. We present one such case of rare associations seen in our clinical practice. A 20-year-old woman was brought to our emergency room with headache, breathlessness, and altered sensorium. Clinical and biochemical evaluation revealed SVT, DKA, and right lower limb ALI. On enquiry, the patient was found to be diagnosed with pituitary adenoma 2 years ago and lost to follow-up. PA was detected on neuroimaging and confirmed histopathologically. Possibility of PA presenting as DKA and its sequelae exists.

Newer advances in lesional surgery for movement disorders.

An analysis of the existing literature on lesioning for movement disorders was undertaken to review lesion therapy and its advances. Advances in imaging technology and electrophysiological techniques used for localization of brain structures and its functions, such as microelectrode recordings and macrostimulation, have greatly improved the ability to accurately identify the target nuclei such as the ventrointermediate nucleus (Vim), globus pallidus interna (GPi) and subthalamic nucleus (STN). Many important changes are happening in the understanding of lesion making. Its application as a cheaper modality of treatment; being less cumbersome; having a wider geographical appeal; and more options to create a lesion, appeals to the clinician. The procedure is undergoing a revival.

Emergency Surgery for Refractory Status Epilepticus.

BACKGROUND: Management of refractory status epilepticus in children is extremely challenging. CASE CHARACTERISTICS: Two children with medically refractory status epilepticus, both of whom had lesional pathology on MRI and concordant data on EEG and PET scan. INTERVENTION: Emergency hemispherotomy performed in both patients. A complete, sustained seizure freedom obtained postoperatively. MESSAGE: Emergency surgery is a treatment option in selected cases of drug refractory status epilepticus with lesional pathology and concordant data.

Acanthamoeba encephalitis in patient with systemic lupus, India.

We report a fatal case of encephalitis caused by Acanthamoeba in a 24-year-old woman from India with systemic lupus erythematosus. Diagnosis was made by identification of amebas in brain sections by immunofluorescence analysis and confirmed by demonstrating Acanthamoeba mitochondrial 16S rRNA gene DNA in brain tissue sections.