Factors predicting seizure outcome after surgical excision of meningioma: SOLID-C guideline for prophylactic AED.

BACKGROUND: Seizures are commonly seen among meningioma patients and may cause impaired quality of life. These patients can be effectively treated with surgery. Still, many patients have persistent seizure episodes after surgery. The factors which are associated with worsening of seizure episodes remain critical in improving the quality of life for such patients. In this study, we aim to analyze the clinical and histopathological factors to predict the post excision seizure-outcome in meningioma and need of antiepileptic prophylaxis for these patients. METHODS: Adult patients who underwent primary resection of meningioma at our institute between 2007 and 2020 were included in the study. Eligibility criteria were as follows: (i) Surgery for newly-diagnosed biopsy proven meningioma, (ii) Presence of pre-operative seizure (iii) A follow-up period ≥ 12 months. RESULTS: Of the 1145 patients in this series, 333 patients were recruited in study. The major determinants of prophylactic anti-epileptic were tumour size (S), Oedema (O), location (L), inclusion body (I), antiepileptic drugs (D) and surgical complication (C). The factors independently associated with poor seizure control after surgical resection were presence of brain parenchyma invasion (p < 0.001), pre-operative use of > 2 antiepileptics (p = 0.016) and presence of intranuclear inclusion bodies (p = 0.001). CONCLUSIONS: The identification and consideration of factors associated with prolonged seizure control after surgery may help us to guide treatment strategies aimed at improving the quality of life for patients with meningiomas. Authors have proposed a SOLID-C guideline to avoid the blanket approach of prophylactic AED in patients undergoing for meningioma resection.

Intraventricular papillary glioneuronal tumor with high proliferation index and CD117 positivity: Report of an atypical case and review of literature.

Papillary glioneuronal tumors are rare neoplasm, accounting only <0.02% of all intracranial tumors. They are generally low grade usually occur in the temporal lobe near the third ventricle. We report an extremely rare case of intraventricular tumor with a high proliferation index. CD 117 expression found in our case is the first study to the best of our knowledge to be described in these tumors. The clinical and diagnostic significance of this finding is subject to further studies.

Insular glioblastoma: surgical challenges, survival outcomes and prognostic factors.

BACKGROUND: Insular gliomas are unique, challenging and evoke a lot of interest amongst neurosurgeons. Publications on insular glioma generally focus on the surgical intricacies and extent of resection pertaining to the low-grade gliomas. Insular glioblastomas (iGBM) have not been analysed separately before. METHODS: Histologically proven WHO grade IV gliomas involving the insula over a 9-year period were studied. Their clinical presentation, radiological features, surgical findings and survival outcomes were assessed. Statistical methods were used to determine the favourable predictors of survival. RESULTS: Out of 27 patients (M:F = 2.9:1), 18 (66%) patients had a tumour extension beyond the insula, 10 (37%) of whom had basal ganglia involvement. Total, near total and subtotal excisions were performed in 7 (26%), 9 (33%) and 11 (40.7%) patients, respectively. Twenty-three patients had glioblastoma, while four had gliosarcoma. IDH mutation was negative in six of the seven patients where it was done. Median overall survival was 5 months. Multivariate analysis showed that a female gender (p = 0.013), seizures in the preoperative period (p = 0.048) and completion of adjuvant therapy (p = 0.003) were associated with a longer survival. CONCLUSION: Insular glioblastomas have a poor prognosis. Insular location and certain tumour characteristics often limit the extent of resection of iGBMs. Moreover, postoperative complications sometimes negate the advantages of a radical resection. A female gender, presentation with seizures and completion of adjuvant chemoradiotherapy appear to be good prognostic factors.

Spindle cell carcinoma of male breast: Report of a rare case.

ABSTRACT: We report a rare case of spindle cell carcinoma, a histological subtype of metaplastic breast carcinoma, in a 40-year-old male who presented with an ulcero-proliferative lump in the right breast. Fine-needle aspiration cytology of the lesion showed poorly cohesive clusters of pleomorphic spindle-shaped cells, suggestive of malignant spindle cell tumor. Right mastectomy along with ipsilateral lymph node dissection was performed. Microscopic evaluation revealed a neoplasm comprising interlacing fascicles of oval to spindled pleomorphic cells with brisk mitosis and areas of necrosis. There was no nodal metastasis. Immunohistochemistry revealed a triple-negative phenotype along with diffuse positivity for CK5/6, vimentin, and smooth muscle actin. p63, beta-catenin, and CD34 were negative. The patient subsequently received adjuvant chemotherapy with 5-fluorouracil, adriamycin, and cyclophosphamide regimen and was disease-free at 1-year follow-up.

Thrombosis leading to acute abdomen in corona virus disease- 19:A case series.

Involvement of the gastrointestinal (GI) system in corona virus disease-19 (COVID-19) in form of diarrhea, loss of taste, nausea, and anorexia is common and associated with poor prognosis. COVID-19 is also associated with a hypercoagulable state that mainly involves the pulmonary vasculature. However, GI complications involving thrombosis are observed infrequently. We report two COVID-19 patients who had two different causes of acute abdomen. The first patient was a 49-year-old male diagnosed with an aortic thrombus along with a splenic infarct. He was diagnosed early and successfully managed with anticoagulants. The second patient was a 30-year-old male who developed pain in the abdomen and was found to have features suggestive of peritonitis. A contrast-enhanced computerized tomography (CECT) scan of the abdomen revealed dilated bowel loops. Immediate exploratory laparotomy was performed; he was found to have jejunal perforation with gangrene. Histopathological examination of the resected specimen showed inflammatory cells with edema and thrombotic vessels. However, he succumbed to sepsis and multiorgan failure. Therefore, it is important to investigate cases of acute abdomen in COVID-19 thoroughly and whenever indicated CT angiogram should be obtained.

Endoscopic Keyhole Approach for Intracranial Epidermoid.

Objective In contemporary neurosurgical practice, keyhole endoscopic approach has established its role in various neurosurgical pathologies. Intracranial epidermoid is an ideal pathology for endoscopic keyhole approach as epidermoid is well encapsulated, extra-axial, avascular, and easily suckable. The objective of this study is to share our experience of endoscopic keyhole approach for intracranial epidermoids at various locations as a new minimally invasive neurosurgical approach to deal with these lesions. Materials and Methods We conducted a retrospective study on 26 patients who underwent keyhole pure endoscopic excision of intracranial epidermoid between July 2015 and December 2019. Patient's demographics, clinical features, radiological imaging, and postoperative complications were noted. Follow-up outcome of preoperative symptoms and postoperative complications were also analyzed. Results The mean age of the study population was 30.5 years with a mean follow-up of 30 months. The common presenting features were headache, hearing loss, and trigeminal neuralgic pain. Gross total resection was achieved in 73.1% cases, while near total resection and subtotal resection were achieved in 19.2 and 7.7% cases, respectively. In the follow-up, maximal improvement was seen in trigeminal neuralgic pain (83%) and headache (66.7%). Major postoperative complications were facial nerve paresis, lower cranial nerve paresis, and transient facial hypoesthesia, most of which improved over time. None of the patients required resurgery till date. Statistical Analysis Patients' data were analyzed using SPSS software version 23 (Statistical Package for Social Sciences, IBM, Chicago, United States). Conclusion This study demonstrates that with careful patient selection, endoscopic keyhole excision of epidermoid is a good alternative to conventional microsurgical excision with comparable surgical and functional outcomes.

Intracardiac hydatid cyst located in right ventricular outflow tract: a rare site.

Intracardiac hydatid cyst is relatively uncommon and involvement of right ventricular outflow tract is extremely rare. We report a rare case of intracardiac hydatid cyst involving the right ventricular outflow tract and do a review of literature.

Calvarial Lesions: A Tertiary Centre's Experience Over Fifteen Years.

BACKGROUND: The human calvaria harbors a variety of pathology and majority of them are incidentally noticed as painless swelling. The aim of the present study is to describe the histopathological subtypes of calvarial lesions, their management and factors affecting their surgical outcome at a tertiary care referral center. MATERIAL AND METHODS: All patients who underwent excision of the calvarial lesions over the last 15 years (from January 2005 to July 2019) were included in this study. Patients having calvarial pathology of infective origin and recurrent lesions were excluded. Any patient with multiple calvarial lesions who have been operated more than one time for same histopathological diagnosis was counted as one patient. We studied Karnofsky Performance Status (KPS) scores and radiological changes at 3-month follow up. RESULTS: Total 65 patients were recruited in this retrospective observational study. The median age of patients in the study was 29 years (range: 8 years to 68 years). Fibrous dysplasia 20 (30.7%) was the commonest lesion while metastatic thyroid carcinoma 3 (4.6%) was the most common malignant pathology. Complete excision was performed in 51 (78.5%) of patients while in 14 (21.5%) cases, subtotal or near total decompression were achieved. After three months of surgery, there was significant improvement in the KPS score (P < 0.00001). Duration of follow up ranges from 6 months to 5 years with 4 mortality in the study. CONCLUSIONS: Most of the calvarial tumors were benign and surgically addressable. The malignant lesions were scattered with diverse underlying pathology and required individualized holistic approach.

Efficacy of Silicone Conduit in the Rat Sciatic Nerve Repair Model: Journey of a Thousand Miles.

BACKGROUND: A lot of options have been tried for bridging the two ends of the injured nerves. Researchers have used decellularized nerve grafts, artificial materials and even nerve growth factors to augment functional recovery. These materials are either costly or inaccessible in developing world. OBJECTIVE: The study aimed to evaluate the efficacy of the silicone conduit in a rat sciatic nerve injury model. MATERIALS AND METHODS: 24 healthy Sprague-Dawley (SD) rats (250-300 grams; 8-10 weeks) were used and right sciatic nerve was exposed; transected and re-anastomosed by two different methods in 16 rats. In control group, n = 8 (Group I) the sciatic nerve was untouched; Group II (reverse nerve anastomosis, n = 8): 1-centimeter of nerve was cut and re-anastomosed by using 10-0 monofilament suture; Group III (silicone conduit, n = 8) 1-centimeter nerve segment was cut, replaced by silicone conduit and supplemented by fibrin glue]. Evaluation of nerve recovery was done functionally (pain threshold and sciatic functional index) over 3 months and histologically and electron microscopically. RESULTS: Functional results showed a trend of clinical improvement in Group III and II but recovery was poor and never reached up to normal. Histopathological and electron microscopic results showed an incomplete axonal regeneration in Groups II and III. Psychological analyses showed that no outwards signs of stress were present and none of the rats showed paw biting and teeth chattering. CONCLUSION: The silicone conduit graft may be an economical and effective alternative to presently available interposition grafts, however for short segments only.

A clinico-pathological and neuro-radiological study of angiomatous meningioma: Aggressive look with benign behaviour.

Angiomatous meningioma is a rare variant tumor classified as WHO grade 1 meningioma and accounts for about 2.1% of all meningioma. Their clinical presentation, surgical management, and prognosis are almost similar to the classical meningioma. Despite of benign nature and being comparatively small in size, they look aggressive on radiology images like massive peritumoral edema and intense contrast enhancement. Being a unique subtype of meningioma, the studies on angiomatous meningioma are very limited. In this cross sectional retrospective study, we described the clinical presentation, radiology, histopathological features and differential diagnosis of 30 cases of angiomatous meningioma from a single centre. The clinical parameters include demographic profile, symptoms and radiological findings including location, extent, pattern, histopathology with World Health Organization (WHO) grade-2016, extent of tumour excision, recurrence and surgical outcome. Incidence of angiomatous meningioma in our study was 2.46% with male predominance. The most common location in our study was convexity. 27 out of 30 had histopathology reports of angiomatous meningioma and 3 had lipoangiomatous meningioma. The high vascularity and disproportionate peri-tumoral edema makes it a surgical challenge for excision. The complications and surgical outcome were analysed. The radiological anticipation of tumour subtype, meticulous pre-operative planning and intraoperative precautions remains a key for success.

Endoscopic Third Ventriculostomy and Simultaneous Tumor Biopsy in Pineal Region Tumors using the "Single Burr Hole" Technique: An Analysis of 34 Cases.

BACKGROUND: Pineal region tumors often present with hydrocephalus. Endoscopic third ventriculostomy (ETV) and simultaneous tumor biopsy remain a minimally invasive procedure offering both diagnostic and therapeutic advantages in the management of these tumors. However, different operative techniques have been described in the literature. AIM: The aim is to study the ETV success rate, diagnostic rate of simultaneous tumor biopsy, complications, and follow-up of patients of pineal region tumors managed with ETV and simultaneous tumor biopsy using the single burr hole technique. METHODS: The study was performed by retrospectively reviewing the records of patients of pineal region tumors managed by simultaneous ETV and tumor biopsy using a "single burr hole" technique from January 2012 to December 2019. RESULTS: Thirty-four patients (22 males and 12 females) with a mean age of 28.7 years were analyzed. ETV was successful in relieving hydrocephalus in 29 (87.8%) patients. Three patients needed a ventriculoperitoneal shunt, and one required Ommaya reservoir placement for persistent hydrocephalus. Histological diagnosis was successfully established in 26 (78.8%) patients. There were two procedure-related mortalities. Two patients underwent craniotomy and tumor excision subsequently. Radiotherapy was given to 11 patients, and 9 patients were managed by observation alone. The mean follow-up of our study was 15.8 months. CONCLUSIONS: Simultaneous ETV and tumor biopsy using a single burr hole technique is a safe, minimally invasive procedure for the management of pineal region tumors.

Intradural Extramedullary Nonconus Nonfilum Spinal Ependymomas: Report of a Rare Variant and Newer Insights into Their Histogenesis with Proposal of a Classification Scheme and a Management Algorithm Based on a Review of Literature.

BACKGROUND: Ependymomas are common intramedullary spinal tumors but there are scattered reports of this tumor presenting with exophytic growth patterns masquerading as intradural extramedullary (IDEM) tumors. Such IDEM ependymomas are seldom suspected preoperatively and it is only during surgery that their existence is revealed. Little is known of such rare growth patterns of an otherwise common intramedullary spinal cord tumor, their characteristics, and their management considerations. METHODS: We present a case of an exophytic dorsal ependymoma with a stalk like attachment to the spinal cord and the surgical management in a 24-year old woman. An extensive literature search was carried out on all prominent databases to find out similar cases reported earlier. We excluded filum/conus ependymoma, purely extradural spinal ependymoma as well as the extraspinal ependymomas. Details of each case reported before were obtained and tabulated. RESULTS: IDEM ependymomas have been reported in 54 patients so far, including the present case. Four patterns of growth emerged from the literature review: intramedullary ependymoma with exophytic component (group I, n = 9), exophytic IDEM ependymoma without intramedullary component (group II, n = 6), IDEM ependymoma arising from nerve roots (group III, n = 7), and pure IDEM ependymoma (group IV, n = 32). Except in group I, IDEM ependymoma affects females more frequently, without any specific age predilection. Thoracic spinal cord/canal is the most common location across all groups. Multifocal disease, craniospinal dissemination, and recurrences tend to be maximum in group IV. CONCLUSIONS: IDEM ependymomas are more common in thoracic segment of the cord and broadly divisible into 4 subgroups. We suggest a subpial origin of group II IDEM ependymomas. We also advocate proliferation index estimation in grade II ependymomas to enable formulation of an optimal management plan.

Meningioma in a Postrenal Transplant Case: More than Meets the Eye.

BACKGROUND: Patients with a renal transplant are an ever-increasing demographic. Their life expectancy is also on the rise and thus malignancies or tumors in these cases are more frequent. These patients are often on immunosuppressive drugs that are known to cause changes in the microvasculature, especially of the deep white matter. However, benign dural-based lesions are a rarity in these cases with very few (<5) ever being reported. Imaging findings in such cases are altered, which leads to an altered set of differential diagnosis. CASE DESCRIPTION: We present a case of a right parasagittal lesion in case of postrenal transplant with imaging findings suggestive of an inflammatory lesion. The lesion was excised and histopathology was that of a fibrous meningioma. Pathological basis of altered imaging is discussed and potential causes elaborated along with a thorough review of similar cases and their findings. CONCLUSIONS: Renal transplants and long-term survival are now a reality; calcineurin inhibitors are a staple for these cases. The drugs alter imaging findings and hence cases need to be carefully evaluated with a host of differential diagnosis. Knowledge of these changes is now necessary for these new spectra of cases.

Endoscopic Keyhole Retromastoid Approach in Neurosurgical Practice: Ant-Man's View of the Neurosurgical Marvel.

BACKGROUND: Endoscopy is now a staple of any neurosurgical practice. The versatility of this approach and gratifying results has resulted in its increased popularity. The objective of this paper is to report our experience of managing various cerebellopontine angle (CPA) pathologies by endoscopic keyhole retromastoid suboccipital craniectomy (RMSO) approach. METHODS: A retrospective review of the medical records of patients operated in our department by endoscopic keyhole RMSO approach was done along with a collection of relevant patient particulars. RESULTS: Forty-four patients (24 men and 20 women) were operated via an endoscopic keyhole RMSO approach for various lesions in and around the CPA. The craniectomy was of 2.0-2.5 cm in size. An endoscope was used as the sole visualizing tool throughout the procedure in all cases. Primarily 2 kinds of pathologies were approached: neoplasms, mostly benign (n = 33), and vascular loops (n = 11). The extent of excision in 33 tumor cases was gross total (n = 20), near total (n = 12), and subtotal (n = 1). In cases of a vascular loop, microvascular decompression was performed. Anatomic facial nerve preservation was ensured in all cases of vascular loops and in 30 tumor cases. Postoperative complications included new-onset/worsening of facial nerve paresis (n = 12, 27.3%), 9 of which improved in follow-up, transient facial hypoesthesia (n = 2, 4.5%), transient abducens paresis (n = 4, 9%), transient lower cranial nerve paresis (n = 3, 6.8%), pseudomeningocele (n = 1, 2.3%), cerebrospinal fluid leak with meningitis (n = 1, 2.3%) and operative site hematoma (n = 1, 2.3%) which required evacuation. CONCLUSIONS: Endoscopic keyhole RMSO approach is minimally invasive and yields an excellent outcome in the management of various CPA lesions.

Endoscopic Route for Excision of Intraventricular Neurocysticercosis: Light at the End of the Tunnel.

BACKGROUND: Poor sanitation, poor hygiene, and archaic cooking practices have led to neurocysticercosis (NCC) being endemic in India. Apart from a cortical location that leads to seizures, intraventricular NCC can present with hydrocephalus and sudden deterioration in sensorium. Consequently, endoscopic excision plays an important role in its treatment because a dilated ventricle offers a minimally invasive and less traumatic route to the pathology. METHODS: All endoscopically excised intraventricular NCC cases operated were retrospectively analyzed from 2014 to 2017, discussing surgical nuances and postoperative outcome. RESULTS: Twelve such cases were found (mean age, 21.9 ± 8.36 years; 9 men and 3 women). The mean follow-up period was 21.17 ± 13.96 months (range, 2-40 months). The most common site was the aqueduct and fourth ventricle. CONCLUSIONS: An endoscopic approach is a feasible and safe tool for treating this disease. Technical nuances such as entry point and trajectory of endoscope need to be kept in mind while operating.

Surgical outcome in cortical ependymoma: A single centre experience of 18 cases.

Cortical ependymomas (CE) are rare subset of supratentorial ependymoma which are located in the peripheral cortical rim without any connection to the ventricular lining. With limited cases previously reported, current knowledge on diagnosis and management of tumors is lacking. We present the largest single center experience on CE reported so far and highlight their clinico-radiological aspects, histopathological features as well the results of their surgical excision. We studied 18 CE patients undergoing surgical excision at our center between September 2009 to November 2017. Clinical, radiological, histopathological and operative data was obtained from hospital records. Functional assessment of our patients were done using the Karnofsky's performance score (KPS). Survival analysis was done using Kaplan-Meier method and log rank test. Mean age of patients in our study group was 19 ±â€¯11.1 years. Frontal lobe was the most frequently involved region. Features of raised intracranial pressure like holocranial headache (n = 15, 83.33%) and vomiting (n = 9, 50%) were most common presenting complaints in our study. Gross total resection of tumor was achieved in eleven patients (61.11%). Histopathology showed equal number (n = 9) of WHO grade 2 and 3 ependymoma. During 111 months follow-up, four patients (22.22%) developed recurrence and three patients (16.66%) died. Five years overall survival (OS), progression-free survival (PFS) rate were 74.3% and 70.7%. In view of higher risk of progression to higher histo-pathological grade and local recurrence years after surgical excision, a long clinical and radiological follow-up is advised.

Sporadic Cisternal Oculomotor Nerve Schwannoma: A Rare Case with Review of Literature.

Cranial nerve schwannomas usually arise from sensory nerve and the occurrence of schwannoma in a motor nerve is rare, especially in sporadic cases. Oculomotor nerve schwannomas (ONS) are rare and they are unique as they arise from motor nerve. ONS palsy may or may not be the presenting feature of oculomotor schwannoma. We present the case of a young male with ONS, presenting with oculomotor nerve palsy along with features of raised intracranial pressure. Oculomotor schwannoma is described in literature only as case reports, and oculomotor nerve is also a rare site for schwannoma as being a motor nerve. In this article, we describe a case of cisternal ONS with review of pertinent literature.

Paraneoplastic Nephrotic Syndrome in a Patient with Planum Sphenoidale Meningioma.

A 60-year-old homemaker presenting with pedal edema and ascites was found to have a planum sphenoidale meningioma concurrently with nephrotic syndrome. On renal biopsy, the patient was found to have membranous glomerulonephritis. There was complete remission of nephropathy after excision of the meningioma. Nephrotic syndrome has been commonly found in association with malignancies and blood disorders but the association with a meningioma is extremely rare, and only one case has been previously reported as per our knowledge.

C-cell hyperplasia in sporadic and familial medullary thyroid carcinoma.

CONTEXT: C-cell hyperplasia (CCH) is characterized by increased mass of C-cells and has been identified as a precursor condition for medullary thyroid carcinoma (MTC). Varying proportion of MTCs is associated with CCH in different studies. This could be due to the lack of uniformity of the definitions and techniques used to identify CCH in these studies. AIMS: This study aims to study the occurrence, clinicopathological, and immunohistochemical features of CCH in MTC diagnosed during a 22-year period at a tertiary care center in North India and to review the available literature on CCH. MATERIALS AND METHODS: Eighty-seven consecutive cases of MTC were included in the study. Histological evaluation for the presence of CCH and neoplastic CCH was performed. Confirmation of CCH was done by immunohistochemistry for calcitonin and chromogranin. The presence of neoplastic CCH was correlated with clinical factors and prognostic factors. RESULTS: Of 87 cases of MTC included in the study, 71 (82%) patients were sporadic and 16 (18%) had familial MTC. Neoplastic CCH was seen in 12 (75%) familial and in 9 (13%) sporadic MTC. Patients with familial MTC were more frequently associated with neoplastic CCH than sporadic MTC (P < 0.001), were younger (P < 0.001), and had more often bilateral and multifocal tumors (P < 0.001). However, there was no significant difference in mean survival time and progression-free survival in patients with and without CCH. CONCLUSION: CCH, though more common in familial MTC, can also be seen in sporadic tumors. CCH is not associated with patient survival and disease progression.