Robotic excision of a pre-coccygeal nerve root tumor.

Pre-coccygeal ganglioneuroma is a rare clinical entity that presents incidentally or with non-specific symptoms. We present a case of a 25 year old housewife who was incidentally diagnosed with pre-coccygeal ganglioneuroma while getting investigated for primary infertility. The patient had no specific complaints except for irregular menstruation which had started 8 months back. Magnetic resonance imaging (MRI) was suggestive of a presacral and pre-coccygeal lesion. Resection of the tumor was done through the anterior approach using the da Vinci Si robotic system. Two robotic arms and one assistant port were used to completely excise the tumor. Robotic excision of such a tumor mass located at a relatively inaccessible area allows enhanced precision and 3-dimentional (3D) view avoiding damage to important surrounding structures.

Polymorphous Low-Grade Neuroepithelial Tumor of the Young (PLNTY): A Newly Described Entity of Special Radiological Significance.

Intracranial granulomas are a major cause of seizures in India, the most common etiologies being neurocysticercosis and tuberculosis. However, other pathologies including rare low-grade tumors may mimic these granulomas on imaging. In this article, we presented the case of a young woman patient with drug-resistant epilepsy. On imaging, there was a small calcified lesion in the brain parenchyma. In view of concordant electroclinical and imaging data on presurgical evaluation, the lesion was excised and the patient was seizure free. On histopathological evaluation, it was found to be a polymorphous low-grade neuroepithelial tumor of the young (PLNTY) - a rare, recently reported entity that can mimic an intracranial granuloma on imaging.

Treatment of Elizabethkingia meningoseptica Neonatal Meningitis with Combination Systemic and Intraventricular Therapy.

Elizabethkingia meningoseptica, a gram negative bacillus ubiquitous in the hospital environment, is known to infrequently cause serious neonatal infections, particularly meningitis which is associated with high mortality and neuromorbidity in survivors. The authors describe a healthy term newborn with no apparent risk factors who developed Elizabethkingia meningoseptica sepsis and meningitis on day 6 of life. Diagnosis could be established only after a week of the illness by which time the baby developed refractory status epilepticus, ventriculitis and hydrocephalus. The isolate was susceptible to only ciprofloxacin, tigecycline and rifampicin and resistant to vancomycin. Apart from systemic combination therapy for 12 wk, intraventricular vancomycin was given through an external ventricular drain for 4 wk and later a ventriculo-peritoneal (VP) shunt was inserted. With this regime, authors demonstrated microbiologic and clinical cure. The baby is neurologically normal over a 6 mo follow-up.

Neuroschistosomiasis: An Unusual Intracranial Space Occupying Lesion.

BACKGROUND: Neuroschistosomiasis is an uncommonly reported disease. CASE CHARACTERISTICS: An adolescent Indian boy residing in Kenya presented with headache, visual symptoms and seizures, with MRI showing space-occupying lesions in the occipital lobe and cerebellum. OBSERVATION: Brain biopsy was diagnostic of neuro-schistosomiasis; complete recovery was seen with praziquantel and corticosteroid therapy. MESSAGE: This case highlights the importance of considering epidemiology in differential diagnosis and establishing definitive diagnosis even if it is by invasive methods.

Successful treatment of C. auris shunt infection with intraventricular caspofungin.

C. auris is an emerging fungal pathogen with high prevalence of resistance to current antifungal agents. Central nervous system infection with C. auris has been infrequently described. We describe here an adult with nosocomial CSF shunt infection due to multi drug resistant C. auris. Systemic therapy with echinocandin and flucytosine failed. Fortunately, administration of daily intraventricular caspofungin 10 mg for 10 days in conjunction with systemic voriconazole resulted in both clinical and microbiological cure.

Simultaneous living donor liver transplant with sleeve gastrectomy for metabolic syndrome and NASH-related ESLD-First report from India.

Nonalcoholic steatohepatitis (NASH) with morbid obesity and metabolic syndrome is now a common cause of end-stage liver disease (ESLD). These patients are high-risk candidates for liver transplant, and require bariatric surgery to prevent recurrent disease in the new liver. Data reports bariatric surgery after transplant, which maybe difficult because of adhesions between the stomach and liver in living donor liver transplant (LDLT) recipient. We report the first case of combined LDLT with sleeve gastrectomy (SG) from India. A morbidly obese diabetic woman with NASH-related ESLD was planned for combined right lobe LDLT with open SG, in view of failed diet therapy, musculo-skeletal complaints, and restricted mobility. Postoperatively, with liver graft functioning adequately, bariatric diet restrictions resulted in maximum reduction of 25% weight, achieving a target BMI below 30 kg/m2 within 2 months, along with complete cure of diabetes and better ambulation. Thus, combination of LDLT and bariatric surgery in the same sitting is safe and effective in management of metabolic syndrome and associated NASH-related ESLD.

Critical neurological structure sparing radiosurgery of vestibular schwannoma: dosimetric comparison of different techniques and dose prescription methods.

AIM: To investigate potential sparing of critical neurological structures (CNSs) during radiosurgery of vestibular schwannoma (VS) employing different techniques and dose prescription methods. MATERIALS AND METHODS: Fused CT and MRI datasets of eight patients with unilateral VS representing a wide range of target volume (0.48 to 12.08 cc; mean = 3.56 cc), shape and proximity to CNSs such as cochlea, trigeminal nerve and brainstem were re-planned employing static conformal field (SCF), dynamic conformal arc (DCA) and intensity modulated radiosurgery (IMRS) techniques. For every patient, five plans were created for a fixed margin dose of 12 Gy prescribed at 80% in three plans (SCF_80%, DCA_80%, and IMRS_80%) and 50% in another two plans (SCF_50% and DCA_50%). All plans were compared using standard dosimetric indices. RESULTS: Primary goal of every plan to cover ≥99% of target volume with 12 Gy was fulfilled for all patients with minimum significant dose to target (D99) ≥11.99 Gy. Best conformity index (CI Paddick = 0.62 ± 0.12) was observed in SCF_80% and DCA_80% plans whereas; sharpest dose gradient index of 3.40 ± 0.40 was resulted from DCA_50%. All five plans resulted similar maximum dose to brainstem (11.04 ± 2.23 to 11.53 ± 1.10 Gy), cochlea (9.02 ± 1.79 to 10.15 ± 1.26 Gy) and trigeminal nerve (11.55 ± 1.38 to 12.19 ± 2.12 Gy). Among 80% prescription plans, IMRS_80% reduces mean and D5 (P < 0.05) to all CNSs. Prescription of dose at 50% isodose sharpened the dose gradient and significantly (P < 0.05) reduced mean dose and D5 to all CNSs at the cost of target conformity (P = 0.01). Mean dose to cochlea and trigeminal nerve were least at 4.53 ± 0.86 and 6.95 ± 2.02 Gy from SCF_50% and highest at 6.65 ± 0.70 and 8.40 ± 2.11 Gy from DCA_80% plans respectively. CONCLUSION: This dosimetric data provides a guideline for choosing optimum treatment option and scope of inter institutional dosimetric comparison for further improvement in radiosurgery of Vestibular Schwannoma (VS).

Dorsal spinal epidural cavernous hemangioma.

A 61-year-old female patient presented with diffuse pain in the dorsal region of the back of 3 months duration. The magnetic resonance imaging showed an extramedullary, extradural space occupative lesion on the right side of the spinal canal from D5 to D7 vertebral levels. The mass was well marginated and there was no bone involvement. Compression of the adjacent thecal sac was observed, with displacement to the left side. Radiological differential diagnosis included nerve sheath tumor and meningioma. The patient underwent D6 hemilaminectomy under general anesthesia. Intraoperatively, the tumor was purely extradural in location with mild extension into the right foramina. No attachment to the nerves or dura was found. Total excision of the extradural compressing mass was possible as there were preserved planes all around. Histopathology revealed cavernous hemangioma. As illustrated in our case, purely epidural hemangiomas, although uncommon, ought to be considered in the differential diagnosis of spinal epidural soft tissue masses. Findings that may help to differentiate this lesion from the ubiquitous disk prolapse, more common meningiomas and nerve sheath tumors are its ovoid shape, uniform T2 hyperintense signal and lack of anatomic connection with the neighboring intervertebral disk or the exiting nerve root. Entirely extradural lesions with no bone involvement are rare and represent about 12% of all intraspinal hemangiomas.

Spinal cord stimulation for the treatment of refractory unilateral limb pain syndromes.

BACKGROUND: Spinal cord stimulation (SCS) is an established therapy for chronic pain. Its success depends on vigorous patient selection and good follow-up. METHODS: We reviewed 75 patients who had undergone SCS to establish their outcome. 67 of these patients had refractory unilateral limb pain syndrome (RULPS). Their case notes and operative log books were critically reviewed, and when appropriate, telephone interviews were performed (58 patients). RESULTS: 87% of patients responded initially to SCS; at 6 months, the effect waned to 79%, and by 2 years, it improved to 84%. One third of the patients had no revisions, 40% had IPG replacements and the rest had revisions because of lead-related complications (5.3%), epidural complications (mainly fibrosis; 19%) or infections (2.7%). 56% of patients reduced their analgesia, 1.5% stopped taking any painkillers and 46.8% of those who were employed returned to work. CONCLUSION: We feel that SCS is an effective treatment in RULPS and its results depend upon vigorous patient selection and an adequate follow-up and maintenance program.