Intraoperative neuromonitoring for pediatric Chiari decompression: when is it useful?

OBJECTIVE: Surgical treatment for symptomatic Chiari I malformation involves surgical decompression of the craniovertebral junction. Given the proximity of critical brainstem structures, intraoperative neuromonitoring (IONM) is employed for safe decompression in some institutions. However, IONM adds time and cost to the operation, and the benefit to the patient has not been defined. Given the diversity in surgical practices, there is no evidence-based standard of care regarding when to use IONM and which modalities are most helpful. The purpose of this study was to review a single-surgeon experience with IONM in order to determine the sensitivity, specificity, and predictive values of various IONM modalities routinely used in pediatric Chiari I decompression; to examine the associations between patient, clinical, and radiographic characteristics and IONM alerts; and to obtain data regarding the usefulness of these modalities during the surgical process to improve patient outcomes. METHODS: A retrospective review was performed for 300 consecutive pediatric patients who underwent suboccipital craniectomy and C1 laminectomy for Chiari decompression performed by a single surgeon over a 15-year period. Clinical, radiographic, and IONM data were collected. Radiographic measurements of the skull base morphological abnormalities, including clival angle, Chamberlain's line, and Grabb-Oakes line, were compared between patients with and without true IONM signal changes. RESULTS: A total of 291 cases were included, with an age range of 6 months to 19 years. Among 291 cases, somatosensory evoked potentials (SSEPs) were monitored in 291, motor evoked potentials (MEPs) in 209, cranial nerve spontaneous electromyography (sEMG) in 290, and brainstem auditory evoked potentials (BAEPs) in 110. Sensitivity, specificity, positive predictive value, and negative predictive value, respectively, were as follows: 1.00, 1.00, 1.00, and 1.00 for SSEPs; 1.00, 0.99, 0.67, and 1.00 for MEPs; 0.00, 0.88, 0.00, and 1.00 for sEMG; and not appliable, 1.00, not applicable, and 1.00 for BAEPs. Six patients had true IONM signal changes. These patients had radiographic evidence of more severe concomitant craniocervical instability and basilar invagination, with steeper clival angles (124° vs 146°, p = 0.02) and larger Grabb-Oakes lines (10.1 mm vs 6.7 mm, p = 0.02), when compared with the patients without any true IONM changes. CONCLUSIONS: Intraoperative neuromonitoring may be best utilized for patients who show radiographic features of abnormal skull base morphology, defined as a clival angle < 135° or Grabb-Oakes line > 9 mm. When IONM is employed, SSEP and MEP monitoring are the most useful modalities.

De novo epilepsy after microsurgical resection of brain arteriovenous malformations.

OBJECTIVE: Seizures are the second most common presenting symptom of brain arteriovenous malformations (bAVMs) after hemorrhage. Risk factors for preoperative seizures and subsequent seizure control outcomes have been well studied. There is a paucity of literature on postoperative, de novo seizures in initially seizure-naïve patients who undergo resection. Whereas this entity has been documented after craniotomy for a wide variety of neurosurgically treated pathologies including tumors, trauma, and aneurysms, de novo seizures after bAVM resection are poorly studied. Given the debilitating nature of epilepsy, the purpose of this study was to elucidate the incidence and risk factors associated with de novo epilepsy after bAVM resection. METHODS: A retrospective review of patients who underwent resection of a bAVM over a 15-year period was performed. Patients who did not present with seizure were included, and the primary outcome was de novo epilepsy (i.e., a seizure disorder that only manifested after surgery). Demographic, clinical, and radiographic characteristics were compared between patients with and without postoperative epilepsy. Subgroup analysis was conducted on the ruptured bAVMs. RESULTS: From a cohort of 198 patients who underwent resection of a bAVM during the study period, 111 supratentorial ruptured and unruptured bAVMs that did not present with seizure were included. Twenty-one patients (19%) developed de novo epilepsy. One-year cumulative rates of developing de novo epilepsy were 9% for the overall cohort and 8.5% for the cohort with ruptured bAVMs. There were no significant differences between the epilepsy and no-epilepsy groups overall; however, the de novo epilepsy group was younger in the cohort with ruptured bAVMs (28.7 ± 11.7 vs 35.1 ± 19.9 years; p = 0.04). The mean time between resection and first seizure was 26.0 ± 40.4 months, with the longest time being 14 years. Subgroup analysis of the ruptured and endovascular embolization cohorts did not reveal any significant differences. Of the patients who developed poorly controlled epilepsy (defined as Engel class III-IV), all had a history of hemorrhage and half had bAVMs located in the temporal lobe. CONCLUSIONS: De novo epilepsy after bAVM resection occurs at an annual cumulative risk of 9%, with potentially long-term onset. Younger age may be a risk factor in patients who present with rupture. The development of poorly controlled epilepsy may be associated with temporal lobe location and a delay between hemorrhage and resection.

Issues of consent and assent in pediatric neurosurgery.

BACKGROUND: Consent and assent are important concepts to understand in the care of pediatric neurosurgery patients. Recently it has been recommended that although pediatric patients generally do not have the legal capacity to make medical decisions, they be encouraged to be involved in their own care. Given the paucity of information on this topic in the neurosurgery community, the objective is to provide pediatric neurosurgeons with recommendations on how to involve their patients in medical decision-making. METHODS: We review the essential elements and current guidelines of consent and assent for pediatric patients using illustrative neurosurgical case vignettes. RESULTS: The pediatric population ranges widely in cognitive and psychological development making the process of consent and assent quite complex. The role of the child or adolescent in medical decision-making, issues associated with obtaining assent or dissent, and informed refusal of treatment are considered. CONCLUSION: The process of obtaining consent and assent represents a critical yet often overlooked aspect to care of pediatric neurosurgical patients. The pediatric neurosurgeon must be able to distill immensely complex and high-risk procedures into simple, understandable terms. Furthermore, they must recognize when the child's dissent or refusal to treatment is acceptable. In general, allowing children to be involved in their neurosurgical care is empowering and gives them both identity and agency, which is the vital first step to a successful neurosurgical intervention.

Comparison of full-endoscopic and minimally invasive decompression for lumbar spinal stenosis in the setting of degenerative scoliosis and spondylolisthesis.

OBJECTIVEThe management of lumbar spinal stenosis (LSS) with concurrent scoliosis and/or spondylolisthesis remains controversial. Full-endoscopic unilateral laminotomy for bilateral decompression (ULBD) facilitates neural decompression while preserving stabilizing osseoligamentous structures and may be uniquely suited for the treatment of LSS with concurrent mild to moderate degenerative deformity. The safety and efficacy of full-endoscopic versus minimally invasive surgery (MIS) ULBD in this patient population is studied here for the first time.METHODSA retrospective analysis of prospectively collected data was conducted on 45 consecutive LSS patients with concurrent scoliosis (≥ 10° coronal Cobb angle) and/or spondylolisthesis (≥ 3 mm). Patient demographics, operative details, complications, and imaging characteristics were reviewed. Outcomes were quantified using back and leg visual analog scale (VAS) scores and the Oswestry Disability Index (ODI) at 2 weeks, 3 months, and 1 year.RESULTSA total of 26 patients underwent full-endoscopic and 19 underwent MIS-ULBD with an average follow-up period of 12 months. The endoscopic cohort experienced a significantly shorter hospital length of stay (p = 0.014) and fewer adverse events (p = 0.010). Both cohorts experienced significant improvements in VAS and ODI scores at all time points (p < 0.001), but the endoscopic cohort demonstrated significantly better early ODI scores (p = 0.024).CONCLUSIONSEndoscopic and MIS-ULBD result in similar functional outcomes for LSS with mild to moderate deformity, while the endoscopic approach demonstrates a favorable rate of complications. Further studies are required to better delineate the characteristics of spinal deformities amenable to this approach and the durability of functional results.

Loss of histone H3K27me3 identifies a subset of meningiomas with increased risk of recurrence.

Epigenetic patterns on the level of DNA methylation have already been shown to separate clinically relevant subgroups of meningiomas. We here set out to identify potential prognostic implications of epigenetic modification on the level of histones with focus on H3K27 trimethylation (H3K27me3). H3K27me3 was assessed by immunohistochemistry on 232 meningiomas from 232 patients. In 194 cases, trimethylation was detected in tumor cells. In 25 cases, staining was limited to vessels while all tumor cells were negative. Finally, 13 cases yielded equivocal staining patterns. Reduced abundance of H3K27me3 in cases with staining limited to vessels was confirmed by mass spectrometry on a subset of cases. Lack of staining for H3K27me3 in all tumor cells was significantly associated with more rapid progression (p = 0.009). In line, H3K27me3-negative cases were associated with a DNA methylation pattern of the more aggressive types among the recently introduced DNA methylation groups. Also, NF2 and SUFU mutations were enriched among cases with complete lack of H3K27me3 staining in tumor cells (p < 0.0001 and p = 0.029, respectively). H3K27me3 staining pattern added significant prognostic insight into WHO grade II cases and in the compound subset of WHO grade I and II cases (p = 0.04 and p = 0.007, respectively). However, it did not further stratify within WHO grade III cases. Collectively, these data indicate that epigenetic modifications beyond DNA methylation are involved in the aggressiveness of meningioma. It also suggests that H3K27me3 immunohistochemistry might be a useful adjunct in meningioma diagnostics, particularly for cases with WHO grade II histology or at the borderline between WHO grade I and II.

Tumefactive Fibroinflammatory Lesion: A Diagnostic Dilemma.

Tumefactive fibroinflammatory lesions (TFLs) are rare idiopathic benign fibrosclerosing lesions that clinically simulate a malignancy. TFLs are seen more frequently in males between 10 and 74 years of age. The usual site of involvement is the head and neck region, but rarely the extremities may be involved. Coexisting fibrosclerotic processes have been reported including retroperitoneal fibrosis, sclerosing cholangitis, sclerosing mediastinal fibrosis, and orbital pseudotumors. The etiology of this poorly understood entity remains unknown. Possible suggestions include exaggerated responses or autoimmune reactions to any chronic infection. The clinical and radiological appearance of TFLs is that of malignancy, but histopathology reveals them to be a benign process broadly classified under non-neoplastic, fibroinflammatory proliferations. The treatment strategies for these lesions are not well defined and variable and include steroids, surgery, and radiotherapy either alone or in combination. TFLs, albeit not fatal, have a high recurrence rate; patients should, therefore, be kept on long-term follow-up. We describe a young female patient presenting with a rapidly developing cheek swelling, which was diagnosed histopathologically as a TFLs.

Comparative analysis of fresh and dry preserved amniotic membrane transplantation in partial limbal stem cell deficiency.

To compare the role of fresh and dry preserved amniotic membrane transplantation (AMT) in partial limbal stem cell deficiency (LSCD). 30 Patients of partial LSCD involving <180° of cornea of different age group were divided into 2 groups; group A and B. Clinical diagnosis was made on the basis of presence of conjunctival pannus over cornea and loss of limbal palisades of Vogt. After taking impression cytology from the corneal surface, group A patients underwent conjunctival pannus resection followed by fresh AMT while group B patients underwent dry preserved AMT after resection of pannus. Resected specimens were sent for histopathological confirmation of the conjunctival tissue. Serial follow-ups were done at 1, 2, 4, 8, 12 and 24 weeks interval post-operatively. Pre-operative impression cytology revealed goblet cells in 40 and 53.33 % cases of group A and group B respectively. However, histopathological examination confirmed the presence of conjunctival tissue in all cases. All cases in both the groups maintained stable corneal epithelial surface with amelioration of clinical symptoms except for 1 case in group A. At the end of 24 weeks improvement in visual acuity was observed in 40 % cases in both the groups which was not more than 2 Snellen's line in any case. Complete regression of superficial vascularisation was observed in 60 and 53.33 % cases in group A and B respectively while deep vascularisation persisted in all at the end of study period. Recurrence of conjunctival pannus at the same site was observed in 13.33 % in both the groups. One patient (6.66 %) developed post-operative infectious keratitis in group A while no major complications were observed in group B. Both fresh and dry AMT is equally effective in the treatment of partial LSCD. However, the utility of AMT is limited in corneas with long standing tissue scarring and vascularisation secondary to partial LSCD.

Current Indications, Trends, and Long-Term Results of 233 Bypasses to Treat Complex Intracranial Aneurysms: A Location-Specific Analysis.

BACKGROUND AND OBJECTIVES: Advances in endovascular flow diverters have led to a secular shift in the management of brain aneurysms, causing debate on current bypass indications. We therefore sought to investigate the long-term results, current indications, and trends of bypasses for brain aneurysms. METHODS: We retrospectively reviewed bypasses performed between 2005 and 2022 to treat brain aneurysms. Demographic, clinical, and radiological data were collected till the most recent follow-up. Aneurysm occlusion and graft patency was noted on cerebral angiogram in the immediate postoperative, 3-month, and most recent follow-up periods. Clinical outcomes (modified Rankin scores) and complications were assessed at 3 month and most recent follow-up. Trends in bypass volume and graft patency were assessed in 5-year epochs. Results were dichotomized based on aneurysm location to generate location-specific results and trends. RESULTS: Overall, 203 patients (mean age 50 years, 57% female patients) with 207 cerebral aneurysms were treated with 233 cerebral bypasses with a mean follow-up of 2 years. Fusiform morphology was the most common bypass indication. Aneurysm occlusion on immediate postoperative and final follow-up angiogram was 89% (184/207) and 96% (198/207), respectively. Graft patency rate in the immediate postoperative period and most recent follow-up was 95% (222/233) and 92% (215/233), respectively. Of 207 aneurysms, 5 (2%) recurred. Of 203 patients, 81% (165) patients had modified Rankin scores of 0-2 at the 3-month follow-up and 11 patients died (mortality 5%). Although there was a steady decrease in the bypass volume over the study period, the proportion of bypasses for recurrent aneurysms increased serially. Posterior circulation aneurysms had lower rates of aneurysm occlusion and significantly higher incidence of postoperative strokes and deaths (P = .0035), with basilar artery aneurysms having the worst outcomes. CONCLUSION: Bypass indications have evolved with the inception of novel flow diverters. However, they remain relevant in the cerebrovascular surgeon's armamentarium, and long-term results are excellent.

Liver histopathology in scope of hematological disorders.

Liver involvement is commonly seen in various haematological disorders. They present clinically with elevation of liver enzymes and organomegaly, with or without mass lesions. However, liver involvement may be silent in many hematological disorders or there may be specific findings in liver biopsy that can lead to the diagnosis of clinically inapparent hematological disorders. Present review highlights features of hepatic manifestations in various hematological diseases with special emphasis on histopathological findings. Among RBC disorders, secondary hemochromatosis is the commonest among patients with hemolytic anemia; whereas Sickle Cell Hepatopathy is a well known complication in Sickle Cell Disease, characterised by sequestration of sickled RBCs in sinusoids. Vascular complications such as Budd Chiari syndrome and portal venopathy with portal vein thrombosis are seen in patients with myeloproliferative neoplasms. However, sometimes primary hematological disease may remain occult. Various lymphomas show characteristic pattern of hepatic involvement, most common being sinusoidal and portal infiltration. Pattern of infiltration may give clues to different types of lymphomas. Amongst all lymphomas, Diffuse large B cell lymphoma is the most common lymphoma involving liver. Disseminated intravascular coagulation is a fatal systemic condition and liver involvement by widespread fibrin thrombi, is not an exception. Assessing liver histopathology in context of hematological conditions makes better understanding of pathophysiology and progress of these diseases. It is important for hematologists and hepatologist to be aware of possible liver involvement in various hematological diseases presenting with elevated LFTs and have a logical approach to abnormal LFTs.

High-Flow Bypass and Clip Trapping of a Giant Fusiform Middle Cerebral Artery (M1) Aneurysm: Technical Case Instruction.

BACKGROUND AND IMPORTANCE: Giant intracranial aneurysms have a poor natural history with mortality rates of 68% and 80% over 2-year and 5-year, respectively. Cerebral revascularization can provide flow preservation while treating complex aneurysms requiring parent artery sacrifice. In this report, we describe the microsurgical clip trapping and high-flow bypass revascularization for a giant middle cerebral artery (MCA) aneurysm. CLINICAL PRESENTATION: A 19-year-old man was diagnosed with a giant left MCA aneurysm after he suffered a left hemispheric capsular stroke 6 months ago. Since then, the patient recovered from the right hemiparesis and dysarthria with residual symptoms. Neuroimaging demonstrated a giant fusiform aneurysm encompassing the entire M1 segment. The bilobed aneurysm measured 37 × 16 × 15 mm. Endovascular treatment options included partial coiling of the aneurysm followed by deployment of flow-diverting stent spanning from the M2 branch-through the aneurysm neck-into the internal carotid artery. Because of the high risk of lenticulostriate artery stroke with endovascular treatment, the patient opted for microsurgical clip trapping and bypass. The patient consented to the procedure. High-flow bypass from internal carotid artery to M2 MCA was performed using radial artery graft, followed by aneurysm clip trapping using 3 clips. CONCLUSION: We demonstrate the successful microsurgical treatment for a complex case of giant M1 MCA aneurysm with fusiform morphology. High-flow revascularization using radial artery graft helped in achieving good clinical outcome with complete aneurysm occlusion with flow preservation despite the challenging morphology and location. Cerebral bypass continues to be a useful tool to tackle complex intracranial aneurysms.

Correlation of gallstone characteristics with mucosal changes in gall bladder.

BACKGROUND AND AIM: Gallstones are known to produce diverse histopathological changes in the gall bladder. Our aim was to correlate various gallstone characteristics (number, size, weight, volume and morphological type) with the type of mucosal response in gall bladder (inflammation, hyperplasia, metaplasia and carcinoma). METHODS: The study was conducted on 330 open cholecystectomy specimens with complete gallstones. The stones were assessed for various parameters i.e. number, size, weight, volume and morphological type. For microscopy, sections were obtained from the fundus, body and neck of the gallbladder. Additional sections were taken from abnormal looking areas. RESULTS: Out of the 330 cases, 194 (59%) had mixed stones, 84 (25%) combined, 30 (9%) pigment and 22 (7%) had cholesterol stones. Number of stones varied from a single calculus in 131 (39.6%) cases, double in 29 (8.8%) and multiple in the remaining 170 (51.6%) cases. Cholecystitis, hyperplasia, metaplasia and carcinoma were more commonly seen with mixed and multiple stones. The average weight of calculi in cholecystitis was 2.551 gm, in hyperplasia 3.619 gm, metaplasia4.549 gm and 17.96 gm in cases with carcinoma. Similarly, average volume of the stone(s) was 2.664 ml in cholecystitis, 3.742 ml in hyperplasia, 4.532 ml in metaplasia and 19.178 ml in carcinoma. The average calculus size (2.147 cm) was found to be maximum in cases with carcinoma, followed by hyperplasia (1.187 cm), metaplasia (1.145 cm) and cholecystitis (1.136 cm). CONCLUSION: As the weight, volume and size of the stone increases the changes in the gall bladder mucosa changes from cholecystitis, hyperplasia, metaplasia, dysplasia, to carcinoma.

Nephrocalcinosis: a rare presenting manifestation of primary Sjögren's syndrome.

Renal involvement in primary Sjögren's syndrome (pSS) is not uncommon. Autoimmune tubulointerstitial disorders and distal renal tubular acidosis (dRTA) account for majority of the cases of renal involvement. While dRTA may precede the onset of sicca syndrome in pSS, nephrocalcinosis as a presenting manifestation of pSS is rare. Here, to emphasize the need for initiating investigations for pSS in any patient presenting with nephrocalcinosis due to dRTA, we report a 21-year-old woman presenting with nephrocalcinosis long before pSS was objectively diagnosed.

Post hysterectomy mesonephric carcinoma: A case report and literature review.

Mesonephric carcinoma is a rare type of carcinoma seen in the female genital tract. It arises from the mesonephric remnants situated in the broad ligament, lateral wall of the cervix, vagina, and uterine corpus. Very few cases of mesonephric carcinoma have been reported so far in the literature. The sites mentioned in various literatures include the cervix, vagina, or uterus, but we could not find any literature that mentions posthysterectomy vault as a site for mesonephric carcinoma. Here, we report a case of 40-years-old hysterectomised female who presented in the hospital with nodular growth on the vault and complaints of bleeding per vaginum. Microscopy of the lesion did not show typical morphology of mesonephric carcinoma, but immunohistochemistry played a vital role in the diagnosis of this rare tumor.

Cyclin-dependent kinase inhibitor p21 and proliferative marker ki67 in colonic carcinoma.

Objective: Tumor grade employed for colorectal cancer has long been based on the degree of differentiation, which is difficult to judge objectively. The aim of this study was to assess the immunohistochemical expression of p21 and ki67 and their correlation with the histological grading of colorectal carcinoma. Materials and Methods: A total of 45 biopsy specimens of colorectal cancer were pathologically reviewed and correlation of grade and differentiation of tumor was performed with immunostaining. Results: Ki 67 and p21 markers showed inverse relationship. An inverse relationship of p21 was found with tumor grade, differentiation, Dukes staging and lymph node status, whereas no correlation could be found between these parameters and ki67 expression. Conclusion: We found that p21 can be used to assess the grading and metastatic potential of colorectal carcinoma whereas increased Ki67 expression can help us in the diagnosis of malignancy.

Frailty Predicts Postoperative Functional Outcomes After Microsurgical Resection of Ruptured Brain Arteriovenous Malformations in Older Patients.

OBJECTIVE: To determine the effectiveness of the modified Frailty Index-5 (mFI-5) in predicting postoperative functional outcome after microsurgical resection of ruptured brain arteriovenous malformations (bAVMs). METHODS: A retrospective review was performed of patients undergoing microsurgical resection of acutely ruptured bAVMs. Demographics, bAVM characteristics, mFI-5, Ruptured Arteriovenous Malformation Grading Scale (RAGS) score, and Spetzler-Martin (S-M) grade were recorded. Predictive ability of mFI-5 for postoperative functional outcome measured by modified Rankin Scale (mRS) was assessed with univariate and multivariate logistic and linear regression. RAGS score and S-M grade alone were compared with adding mFI-5 to either RAGS score or S-M grade using area under the curve (AUC) analysis. RESULTS: In total, 109 patients were included. For every 1-point increase in mFI-5, there was a lower likelihood of good functional outcome (mRS score ≤2; odds ratio [OR], 0.33; confidence interval [CI], 0.15-0.60; P = 0.011). Healthy patients (mFI-5 = 0) were more likely to have good postoperative outcomes versus frail patients (mFI-5 ≥1) (OR, 3.32; CI, 1.24-8.97; P = 0.017). In multivariate analysis controlling for RAGS score, for every 1-point mFI-5 increase, there was a decreased likelihood of postoperative good functional outcome (OR, 0.32; CI, 0.14-0.63; P = 0.0026) and mFI-5 did not significantly predict secondary outcomes. S-M grade with mFI-5 showed better discrimination for postoperative good functional outcome (AUC 0.616), compared with S-M grade alone (AUC 0.544). RAGS score with mFI-5 showed the best discrimination for postoperative good functional outcome (AUC 0.798), compared with RAGS score alone (AUC 0.721). CONCLUSIONS: Measuring frailty with mFI-5 additive to established bAVM grading systems may improve assessment of individual patient likelihood of postoperative good functional outcome after hemorrhagic bAVM resection.

Clopidogrel hyper-response increases peripheral hemorrhagic complications without increasing intracranial complications in endovascular aneurysm treatments requiring dual antiplatelet therapy.

Clinical significance of increased clopidogrel response measured by VerifyNow P2Y12 assay is unclear; management guidelines are lacking in the context of neuroendovascular intervention. Our objective was to assess whether increased clopidogrel response predicts complications from endovascular aneurysm treatment requiring dual antiplatelet therapy. A single-institution, 9-year retrospective study of patients undergoing endovascular treatments for ruptured and unruptured aneurysms requiring aspirin and clopidogrel was conducted. Patients were grouped according to preoperative platelet inhibition in response to clopidogrel measured by the VerifyNow P2Y12 assay (VNP; P2Y12 reactivity units, PRU). Demographic and clinical features were compared across groups. Hemorrhagic complication rates (intracranial, major extracranial, minor extracranial) and thromboembolic complications (in-stent stenosis, stroke/transient ischemic attack) were compared, controlling for potential confounders and multiple comparisons. Data were collected from 284 patients across 317 procedures. Pre-operative VNP assays identified 9 % Extreme Responders (PRU ≤ 15), 13 % Hyper-Responders (PRU 16-60), 62 % Therapeutic Responders (PRU 61-214), 16 % Hypo-Responders (PRU ≥ 215). Increased response to clopidogrel was associated with increased risk of any hemorrhagic complication (≤60 PRU vs > 60 PRU; 39 % vs 24 %, P = 0.050); all intracranial hemorrhages occurred in patients with PRU > 60. Thromboembolic complications were similar between therapeutic and subtherapeutic patients (<215 PRU vs ≥ 215 PRU; 15 % vs 16 %, P = 0.835). Increased preoperative clopidogrel response is associated with increased rate of extracranial hemorrhagic complications in endovascular aneurysm treatments. Hyper-responders (16-60 PRU) and Extreme Responders (≤15 PRU) were not associated with intracranial hemorrhagic or thrombotic complications. Hypo-responders who underwent adjustment of antiplatelet therapy and neurointerventions did not experience higher rates of complications.

Histomorphological and Morphometric Evaluation of Microvessel Density in Nodal Non-Hodgkin Lymphoma Using CD34 and CD105.

Background Expression of angiogenic markers determined by microvessel density (MVD) could be used as a reliable predictor of prognosis and as a potential target for antiangiogenic therapy in different categories of non-Hodgkin lymphoma (NHL). Aims The aim of this study was to evaluate MVD using immunohistochemical methods and computer-assisted quantitative image analysis in nodal NHL patients and compare CD34 and CD105 expression in lymph nodes of NHL patients. Materials and Methods The present study was conducted on 60 lymph node biopsies received in the Department of Pathology at our tertiary care center for histopathological examination. Representative paraffin-embedded tissue sections were stained with hematoxylin and eosin along with immunohistochemical stains for CD34 and CD105. MVDs were analyzed at 400× using automated image analyzer by two investigators independently. Statistical Analysis Data were calculated, tabulated, and statistically analyzed using SPSS (Statistical Package for Social Studies) statistical program version 18. The values entered were mean of morphometric parameters. In all tests, p -values below 0.05 were regarded as significant. Results MVD was determined by CD34 and CD105 antibody highly correlated with different categories of NHL. Higher MVD was observed in cases of aggressive NHL as compared with indolent NHL and the difference was statistically significantly. MVD using CD105 was correlated more strongly as compared to CD34 with different categories of NHL. Conclusion The present study concluded that NHL exhibits potent angiogenic activity that increased significantly with increasing aggressiveness. The study also demonstrated that CD105 is more specific than CD34 as a marker of neoangiogenesis in NHL.

Optimal panel of immunohistochemistry for the diagnosis of B-cell non-Hodgkin lymphoma using bone marrow biopsy: a tertiary care center study.

BACKGROUND: Morphological diagnosis of non-Hodgkin lymphoma (NHL) is usually based on lymph node biopsy. Bone marrow biopsy (BMB) is important for staging, and morphology alone can be challenging for subtyping. Immunohistochemistry (IHC) allows a more precise diagnosis and characterization of NHL using monoclonal antibodies. However, there is a need for a minimal panel that can provide maximum information at an affordable cost. METHODS: All newly diagnosed cases of B-cell NHL with bone marrow infiltration between 2017 and 2019 were included. BMB was the primary procedure for diagnosing B-cell NHL. Subtyping of lymphomas was performed by immunophenotyping using a panel of monoclonal antibodies on IHC. The primary diagnostic panel of antibodies for B-cell NHL included CD19, CD20, CD79, CD5, CD23, CD10, Kappa, and Lambda. The extended panel of antibodies for further subtyping included CD30, CD45, CD56, Cyclin D1, BCL2, and BCL6. RESULTS: All cases of B-cell NHL were classified into the chronic lymphocytic leukemia (CLL) and non-CLL groups based on morphology and primary IHC panel. In the CLL group, the most significant findings were CD5 expression, CD23 expression, dim CD79 expression, and weak surface immunoglobulin (Ig) positivity. In the non-CLL group, they were CD5 expression, positive or negative CD23 expression, strong CD79 expression, and strong surface Ig expression. An extended panel was used for further subtyping of non-CLL cases, which comprised CD10, Cyclin D1, BCL2, and BCL6. CONCLUSION: We propose a two-tier approach for immunophenotypic analysis of newly diagnosed B-cell NHL cases with a minimum primary panel including CD5, CD23, CD79, Kappa, and Lambda for differentiation into CLL/non-CLL group and Kappa and Lambda for clonality assessment. An extended panel may be used wherever required for further subtyping of non-CLL.

Fine needle aspiration cytology of cervical lymph nodes: Comparison of liquid based cytology (SurePath) and conventional preparation.

BACKGROUND: Fine needle aspiration cytology (FNAC) is the first diagnostic step in patient with cervical lymphadenopathy because of its simplicity, safety and early availability of the results. Liquid-based cytology (LBC) is an alternative processing method which is used for both gynecological and nongynecological samples. Literature reviewed show few studies comparing LBC with conventional preparation (CP). AIM: The present study was undertaken to evaluate the efficacy of LBC and comparison of LBC and CP in cervical lymphadenopathy. MATERIALS AND METHODS: In this prospective study, a total of 75 cases of FNAC with cervical lymphadenopathy were included. The first pass was used for CP followed by LBC with the use of SurePath (SP) technique. Both the smears were compared for cellularity, background containing blood, cell debris, lymphoglandular bodies, stromal fragments, cytoarchitectural pattern, etc., by semiquantitative scoring system. RESULTS: There was no statistical difference in the cellularity, cell architecture, and monolayer cells (P > .05). On the basis of background containing blood, cell debris, lympho-glandular bodies, stromal fragments (P < .001), nuclear, and cytoplasmic details (P < .05), LBC was found to be superior to CP. CONCLUSION: LBC is a relatively simple technique and superior to CP in respect of better nuclear and cytoplasmic details with loss of background blood and debris. It has a diagnostic accuracy equivalent to that of CP. However, use of both LBC and CP can result in better diagnostic accuracy.