Pituitary Adenoma: A review of existing classification systems based on anatomic extension and invasion.

Pituitary adenomas are common, benign tumours, that can be classified in many ways including their functionality, size and anatomical extension. Historically, larger more invasive adenomas with extension into parasellar regions were deemd untreatable. However, with increasing operative sophistication, and more precise and effective radiation options; it is no longer the case, and therefore it becomes even more important for a comprehensive classification system for these tumours. Herein, the authors present an updated review on the available classification systems for large pituitary adenomas, based on their anatomic extension and invasion of adjacent anatomic structures.

Biological characteristics and outcomes of Gliosarcoma.

Gliosarcoma is a highly aggressive primary brain tumour. It is a relatively rare tumour and comprises of two histological components, glial and sarcomatous. Gliosarcomas carry a poorer prognosis than that of Glioblastoma Multiforme (GBM). The current review highlights important histological and radiological features of gliosarcoma in the light of recent literature, and also touches upon the treatment options and outcomes of various types of gliosarcoma.

Prognostic Implications of Histological Clear Cells in High-Grade Intracranial Ependymal Tumors: A Retrospective Analysis from a Tertiary Care Hospital in Pakistan.

BACKGROUND: Clear cell variant in ependymal tumors is rare. We aimed to compare the features and outcome of the World Health Organization (WHO) Grade 3 ependymal tumors with clear cells to the WHO Grade 3 classic anaplastic ependymoma (AE). MATERIALS AND METHODS: A retrospective cohort study conducted at the Department of Neurosurgery, Aga Khan University, Pakistan, from 2003 to 2013. The medical records and radiology of patients with proven histopathology were reviewed. The analysis was done on SPSS 20. RESULTS: Nine cases of clear cell variant and 23 cases of classic AE were found, both of which combined equated to 4% of the total tumor burden in 11 years. The median age of clear cell ependymoma (CCE) and AE were 49 and 37 years, respectively. Presenting symptoms included headache in 66% of CCE and 63% in AE, raised intracranial pressure accounting for 33% of CCE and 54% of AE, dizziness in 22% CCE and 39% AE, while seizures presented equally in both. Supratentorial location was observed in 77% CCE and 48% AE. Both showed hypointense signals on T1-weighted images of magnetic resonance imaging (MRI) while T2-weighted images showed hyperintensity in all cases of CCE but only 80% of AE. MRI characteristics such as the presence of cystic component were found in 89% of CCE and 68% of AE, necrosis in 33% CCE, and 22% AE, hemorrhagic in 22% CCE and 9% AE, and equivalent contrast enhancement. Gross total resection was achieved in 5 (55%) patients of CCE, compared to 6 (26%) patients in AE. Subtotal resection was done in 4 (44%) patients of CCE and 15 (65%) patients of AE. Radiotherapy was given to 5 (55%) patients of CCE and 12 (52%) patients of AE. Recurrence was observed in 77% cases of CCE and 70% of AE, with metastasis in 29% of AE and in only one patient of CCE. Repeat surgery was done in 3 (33%) cases of CCE and 8 (35%) cases of AE. Median progression-free survival and overall survival were 9 and 13 months, respectively, in CCE while 14 and 18 months, respectively, for AE. CONCLUSION: Clear cells in the WHO Grade 3 ependymal tumors are found mainly in a comparatively older adult population with a predilection for supratentorial location and are more aggressive in behavior with poorer outcome than AE.

Delayed spinal cord infarction following anterior cervical surgical decompression.

Anterior cervical discectomy and fusion (ACDF) for cord compression is a safe and effective procedure with good outcomes. However, worsening of myelopathy is the most feared adverse event of the surgery. We report the case of a 36-year-old male patient who presented with an acute non-traumatic C5-6 cervical disc herniation causing incomplete quadriparesis. He underwent an uncomplicated ACDF at C5-6, and after an initial period of improvement, he developed a delayed onset of an anterior cord syndrome on day 3, without any discerning cause. We have reviewed similar cases reported in the literature and believe that our patient's postsurgical course is consistent with a delayed ischaemic/reperfusion injury to the cord following surgical decompression and restoration of blood flow through the anterior spinal artery and we make suggestions for management of such clinical events.

Ependymal tumors with oligodendroglioma like clear cells: Experience from a tertiary care hospital in Pakistan.

BACKGROUND: Ependymal tumors with oligodendroglioma like clear cells have never been reported from Pakistan. We aimed to see the features and outcomes of this rare entity. METHODS: It was retrospective cohort conducted at the Department of Neurosurgery, Aga Khan University from 2003 to 2013. The medical records and radiology of patients with proven histopathology were reviewed. Analysis was done on SPSS 20. RESULTS: Eleven cases of ependymal tumors with clear cells were found, which equated to 1.5% of the total tumor burden in 11 years. The median age was 49 years. Most common presenting symptom was headache 54.5%. Out of 11 patients, 9 patients had a supratentorial tumor. Magnetic resonance imaging showed hypointense signals on T1 and hyperintense signals on T2-weighted images in all cases. Contrast enhancement was found in 9 patients (77.8%), necrosis and hemorrhage was found in 4 (36%) and 3 (27%) patients, respectively. Immunohistochemistry showed glial fibrillary acidic protein and epithelial membrane antigen positivity in all cases. Ki-67 showed high proliferative index in 6 patients. According to the World Health Organization grading of ependymal tumors, 2 patients had Grade II tumors, and 9 patients had Grade III tumors with clear cells. Gross total resection was achieved in 6 (54.5%) and subtotal resection in 5 patients (45.4%). Recurrence was observed in 9 patients. Six patients died of the disease. Median progression-free survival and overall survival was 8 months and 10 months, respectively. CONCLUSION: Ependymal tumors with clear cells presented more commonly in Grade III lesions and were more aggressive in behavior with poorer outcome compared to similar studies.

Surgical management of traumatic extra dural hematoma in children: Experiences and analysis from 24 consecutively treated patients in a developing country.

BACKGROUND: Children with epidural hematoma (EDH) present differently than adults. The outcome of treatment is also different. We aim to report our experiences with EDH in pediatric age group in terms of mode of injury, presenting features, management, and outcomes. We also aim to identify different prognostic indicators in pediatric patients with EDH. METHODS: We prospectively collected data from 24 consecutively surgically treated pediatric patients. The data collected included presenting features, radiological imaging, details of management, and outcomes. Descriptive analysis was performed and different variables were tested for any statistical significance with Glasgow Outcome Score (GOS). RESULTS: There were 19 male and 5 female patients. The mean Glasgow Coma Scale (GCS) score at presentation was 9.3 ± 4.4. Falls were the most common cause of EDH. Outcome assessment was done at 3 month follow up. A total of 15 patients had a GOS score of 5, 4 patients had a GOS score of 4, 2 patients had a GOS score of 3, while 3 patients had a GOS score of 1. On univariate analysis, admitting GCS score, patient's age, the time from injury to admission and injury to surgery, anisocoric pupils at presentation and effacement of basal cisterns were significantly associated with the outcome of GOS score. CONCLUSION: Falls are the most common mode of injury leading to EDH in children. Lower GCS at presentation, younger age at trauma, increased time since trauma to surgery and admission, anisocoria and effacement of basal cisterns are statistically significant variables in surgically treated pediatric patients of EDH that confer a poorer prognosis. A timely surgical intervention can result in excellent outcomes.