Infra-tentorial brain tumor subtypes in children and adults-surgical outcome in an ethnic population with a single regional tertiary center.

BACKGROUND: To analyze clinically and radiologically the surgical outcome like residual disease, progression of disease, recurrence, disabilities, event-free survival (EFS), and mortality of different infra-tentorial tumor subtypes in children and adults of a strictly non-migratory and ethnic population. METHODS: The 410 histologically proved, out of 589, infra-tentorial brain tumor patients were analyzed clinically and by the imaging post-surgically in a single tertiary center for an ethnic region. In this analytico-observational study, retrospectively postoperative records of 589 infra-tentorial brain tumors from November 1998 to December 2018 (20 years) were retrieved, scrutinized, and compiled. The post-operative clinic-radiological records of 410 patients with proved histopathological examination results were included. Statistical law of variance was applied where-ever necessary. RESULTS: The 63.2% of the all 410 operated infra-tentorial brain tumors were males while females predominated in meningiomas and pineoblastomas. About 31.7% infra-tentorial tumors were children (below 18 years). About 54.1% cases were histologically malignant. The residual tumors comprised 40.2% and symptoms of disease-progression occurred in 10.9%. The tumor recurrence occurred in 14.3% while 6.0% patients developed severe disability. The overall mortality was 11.4% but 18.9% in malignant tumors. The event-free survival (EFS) for all the patients was 66.0%, patients with malignancies had 47.7% and benign group had 87.7%. CONCLUSION: The study, surgical outcome of infra-tentorial brain tumor subtypes in children and adults (approx. 1/3rd of patients being children), conducted in a tertiary center at a remote land-locked location with non-migratory ethnic population as its catchment area, has a significant epidemiological value for the community and the region.

Correlation between Intraoperative Serum Lactate and New-Onset Postoperative Neurodeficits in Patients Undergoing Elective Craniotomies.

Background: Elevated lactate levels in neurosurgical patients are seen in brain tumors, traumatic brain-injury, brain infarction, and subarachnoid hemorrhage. Hyperlactatemia during craniotomy may be caused by hypotension due to multiple factors. Recently, intraoperative hyperlactatemia has been associated with fresh-onset neurodeficits. Aims: We studied the prevalence of hyperlactatemia in patients undergoing craniotomy and relationship between intraoperative hyperlactatemia and development of new postoperative neurodeficit. Study Design: Eighty-six patients, American Society of Anesthesiologists Classes I,II and III, undergoing elective craniotomy for neurosurgical indications were included in this prospective, observational study in a tertiary care center. Materials and Methods: Baseline, intraoperative, and postoperative (upto 12 h) lactate levels were noted. Neurological examination to detect new-onset neurodeficits was done at intervals up to 72 h postoperatively. Lactate levels were compared between patients who developed neurodeficits and those who did not develop neurodeficits postoperatively. Statistical Analysis: Statistical analysis of the correlation between intraoperative hyperlactatemia and fresh postoperative neurodeficit was done using the Chi-square test. Results: The prevalence of intraoperative hyperlactatemia was found to be 52.3% and that of fresh-onset postoperative neurodeficits was 31.4%. The relationship between the two was statistically insignificant (P > 0.05). Conclusion: The intraoperative hyperlactatemia is not correlated with the development of fresh-onset postoperative neurodeficit. Implications: There may be no relationship between the intraoperative lactate levels and fresh-onset postoperative neurodeficits. Multifactorial reasons may be responsible for increased lactate levels which need to be identified by further research.

Histopathological Pattern and Outcome of Posterior Fossa Tumors in Children and Adults - A 20-Year Experience.

CONTEXT: The postoperative quality and span of life in posterior fossa tumors (PFTs) is complicated by the residual disease, progression, recurrence, disabilities, and mortality. AIMS: The aim of this study is to analyze the link between histopathological type of tumor and outcome in an ethnic Himalayan population of India. SETTINGS AND DESIGN: The histopathological records of 410 out of 589 patients were compared with their clinical outcome up to the 1st postoperative year in a single center which amounts to regional epidemiological value of PFTs. MATERIALS AND METHODS: In this observational study, retrospectively postoperative records of 589 PFTs from November 1990 to December 2010 (20 years) were retrieved, scrutinized, and observed. The postoperative records of 410 patients with proved histopathological examination results were included. STATISTICAL ANALYSIS USED: The statistical law of variance was applied wherever necessary. RESULTS: About 63.2% of 410 operated PTFs were males while females predominated in meningiomas and pineoblastomas. About 31.7% of PFTs were children (below 18 years.). About 54.1% of the cases were histologically malignant. The residual tumors comprised 40.2%, and symptoms of disease progression occurred in 10.9%. The tumor recurrence occurred in 14.3% while 6.0% of the patients developed severe disability. The overall mortality was 11.4% up to the 1st postoperative year, with 18.9% in malignant patients. The first 1-year event-free survival (EFS) for all the patients was 66.0%. While the patients with malignancies had the first 1-year EFS of 47.7%, the histologically benign group had 87.7%. CONCLUSION: The first 1-year postoperative EFS of histologically benign and some malignant PFTs both in children and adults such as pilocytic astrocytomas, ependymomas, and pineoblastomas was much better (87.7%) than other malignant PTFs.

Alveolar Soft Part Sarcoma Metastasizing to the Brain: A Rare Entity Revisited with Review of Recent Literature.

A 20-year-old male patient presented with a recent history of two episodes of seizures and Glasgow Coma Scale of E3V3M6. He was drowsy at presentation with bradycardia. On further examination, he was found to be having a 10 × 6cm well-circumscribed mass in the right medial thigh whose fine needle aspiration cytology was suggestive of soft tissue sarcoma. Contrast-enhanced magnetic resonance imaging brain showed enhancing lobulated lesions in bilateral hemispheres with significant edema. A decision to decompress the intracranial space occupying lesion was taken. Left-sided larger brain lesions underwent total gross excision followed by excision of the thigh mass. Histopathology of brain lesion was suggestive of metastatic deposits of alveolar soft part sarcoma, whereas the thigh mass was suggestive of alveolar soft part sarcoma grade 2 according to Fédération Nationale des Centres de Lutte Contre Le Cancer grading system. Postoperative course of the patient was unremarkable and his general condition improved remarkably (Functional Assessment of Cancer Therapy-Brain version 4 score improvement >50% at 1 month). He is in follow-up for the last 12 months and currently has completed chemoradiotherapy and is living a self-sufficient life. Though patients with aforementioned rare diagnosis have overall poor prognosis, decompressive craniotomy with metastasectomy may improve the overall quality of life of such young patients, and further chemoradiotherapy may help in prolonging life with acceptable level of comorbidity. This case is being discussed here in terms of the rarity of the final diagnosis, the management strategy used, and the quality of life improvement.

Evaluation of Role of Electrophysiological Studies in Patients with Lumbar Disc Disease.

BACKGROUND: The role of the electrophysiologic studies in peripheral nerves and muscles of lower limbs (including paraspinal muscles) in prolapsed lumbar intervertebral discs has been studied with equivocal results. Pre- and post-operative electrodiagnostic studies have not been compared much. AIMS AND OBJECTIVES: To study the role of the electrophysiologic studies in prolapsed lumbar/lumbosacral intervertebral discs for finding the association between clinical findings and electrophysiological changes and to compare the electrophysiologic studies pre- and post-operatively. MATERIALS AND METHODS: The study was conducted from July 2014 to June 2016 on fifty patients who were admitted in the department of neurological surgery with lumbar disc prolapse and all these patients were subjected to surgery. Both pre- and post-operative (from 1 to 6 months after surgery) electrophysiological studies were conducted and compared. RESULTS: As per the electromyographic (EMG) abnormalities, the most common levels of intervertebral disc prolapse were L4-L5 and L5-S1 accounting for 32% of cases each followed by L5-S1 level which was seen in 28% of patients with L2-L3, L3-L4, and L4-L5 prolapsed intervertebral disc (PIVD) and L3-L4 and L4-L5 PIVD were seen in 4% of cases each. Of the 50 patients, EMG findings correlated with operative findings in 37 (74%) patients, however operative findings did not correlate with EMG findings in 13 (26%) patients. CONCLUSION: In compressive lesions of nerve roots (due to disc prolapsed), the EMG method has a high degree of accuracy in determining not only the presence of such lesions but also their exact location. EMG is accurate when correlated with the operative findings.

Osteoporosis Presenting as Low Backache: An Entity not Uncommon to be Missed.

INTRODUCTION: Low backache (LBA) is highly prevalent in osteoporotic patients and affects their quality of life. Overall, osteoporosis incidence is greater in females than in males, and osteoporotic fractures typically occur with only modest or moderate trauma. AIMS AND OBJECTIVES: To evaluate osteoporosis as a cause of LBA in patients attending a neurosurgical outpatient department and to study various risk factors associated with it. MATERIALS AND METHODS: The study entitled "Osteoporosis presenting as LBA: An entity not uncommon to be missed" was a 2-year hospital-based study conducted from August 2014 to July 2016 in a prospective manner and included 100 patients of osteoporosis with LBA. Analysis of records included their chief complaints, signs and symptoms, diagnostic investigations performed, treatment modalities they underwent, and further recommended management carried on them. RESULTS: Out of total 100 patients evaluated, 33 (33%) were male and 67 (67%) were female; the age of patients was in the range of 35-70 years (mean 56.54 ± 91). The number of patients with a significant medical or surgical history was 31 (31%). The history of drug intake such as thyroxine, steroids, and antiepileptics was present in a total of 11 patients out of which 10 were female and one was male. Regarding lifestyle characteristics of studied patients, a total number of 72 (72%) were having sedentary habits with 15 (45.5%) males and 57 (85.1) females, the total number of moderate workers was 19 (27.3) males and 10 (14.9%) females, and heavy workers were 9 (9%) with 9 (27.3) males and 0 (0%) female. CONCLUSION: LBA is highly prevalent in osteoporotic patients especially in women. The incidence of osteoporosis and LBA increased with low body mass index, increasing age, and duration of menopause. The various risk factors for osteoporosis include smoking, history of medical diseases such as diabetes mellitus, history of hysterectomy, and history of antiepileptic, thyroxine, and steroid intake.

Coccygectomy for Coccygodynia: A Single Center Experience Over 5 Years.

INTRODUCTION: Coccygodynia refers to a pathological condition in which pain occurs in the coccyx or its immediate vicinity. The pain is usually provoked by sitting or rising from sitting. Several studies have reported good or excellent results after coccygectomy especially in patients who are refractory to conservative treatment. AIMS AND OBJECTIVES: This study aims to evaluate the role and effectiveness of coccygectomy in chronic refractory coccygodynia. MATERIALS AND METHODS: Between January 2011 and January 2015, 16 consecutive patients (4 males and 12 females) who underwent surgical coccygectomy were enrolled prospectively in the study. All patients suffered from treatment-resistant coccygodynia and had exhausted conservative therapeutic options for at least 6 months before undergoing surgery. The same surgeon performed a complete coccygectomy on all patients. Postoperative outcomes included measurements of pain relief and degree of patient satisfaction with the procedure's results. RESULTS: The average age of patient was 37.93 years (range: 25-53 years), and the male to female ratio was 1:3. The median duration of patient-reported symptoms prior to surgery was 24 months. The most common cause of coccygodynia was direct or indirect trauma, recorded in 11 patients (68.75%). Idiopathic coccygodynia was five cases (31.25%). The number of patients with outcomes rated as "excellent," "good," "fair," and "poor" were 12, 2, 1, and 1, respectively. The favorable result (excellent or good) was 87.5%. The self-reported visual analog scale (VAS) was significantly improved by surgery. The mean VAS preoperatively was 9.62, and postoperatively it was 2.25 (P < 0.001). There were two infections (12.5%) among the 16 patients which were managed conservatively. CONCLUSIONS: Coccygectomy for chronic intractable coccygodynia is simple and effective, with a low complication rate.

Profile of High Grade Gliomas - A Single Center Experience.

INTRODUCTION: The term high grade glioma (HGG), is usually used to describe WHO grade III and IV tumours. There has been a recent increase in incidence of HGGs in the Western world, particularly in the elderly population. This probably reflects the easy availability of vastly improved diagnostic imaging. A five year retroprospective study was planned to study demography, clinical presentation, imaging, surgical intervention, histopathological examination of specimens and postoperative outcome of patients of high grade gliomas. OBJECTIVES: To determine the demographic, clinical, histopathogical and radiological profile of patients of High Grade Gliomas (HGG) and to ascertain post-operative mortality at 24 hours and 7 days Material and Methods: The present study of 226 cases from our institute for the last 5 years (retrospective 3 years and prospective 2 years) extending from August 2010 to July 2015 is based on study about demography, clinical presentation, imaging, surgical intervention, histopathological examination of specimens and postoperative outcome. The clinic-pathological vis-a-vis imaging was also studied. The analyzed data from the results and observations of this study were compared with the previous studies. RESULTS: The study was retrospective as well as prospective. Total of 226 patients were registered. Out of these, 225 patients were operated (except one patient). The provisional diagnosis was based on the radio-imaging basis and the final diagnosis confirmed by histopathological examination. Majority of patients operated for HGG, irrespective of the procedure or extent of resection had good surgical outcome after the procedure. CONCLUSION: The overall survival is multifactorial in HGGs. The surgical intervention particularly in patients with features of raised ICP due to mass lesion provides symptomatic relief and improves quality of life in majority of patients and are discharged reasonably in better state of health.

Significant Effect of Anti-tyrosine Kinase Inhibitor (Gefitinib) on Overall Survival of the Glioblastoma Multiforme Patients in the Backdrop of Mutational Status of Epidermal Growth Factor Receptor and PTEN Genes.

INTRODUCTION: We aimed to assess the effect of anti-tyrosine kinase inhibitors (TKIs) (gefitinib) in overall survival (OS) of the glioblastoma multiforme (GBM) patients in the backdrop of mutational status of epidermal growth factor receptor (EGFR) and PTEN genes. MATERIALS AND METHODS: All the patients subjected to resection or biopsies were put on gefitinib, and radiotherapy was delivered as per the hospital protocol. EGFR and PTEN mutational spectrum was performed by single-strand conformation polymorphism followed by DNA sequencing. RESULTS: In total, 50% GBM tumors had mutation either in EGFR or PTEN. Median progression-free survival (PFS) and OS observed in patients with EGFR +ve/PTEN -ve were significantly favorable (P < 0.05) which aggregated to 9(7, 11) months and 20 (16, 24) months, respectively, than 6 (4, 8) months and 13 (7, 19) months in patients with PTEN +ve/EGFR -ve. Patients positive for both EGFR/PTEN had lower disease-free survival and OS of 6 and 9 months as compared to 6 (5, 7) and 14 (12, 24) months for those negative for both EGFR/PTEN. CONCLUSIONS: We conclude that EGFR gene alterations with wild-type PTEN are associated with significantly better PFS and OS in patients treated with anti-TKIs (gefitinib). Combined EGFR and PTEN gene mutation is associated with significantly poor response to gefitinib in terms of median OS.

A Unique Case of Primary Intracranial Melanoma.

Primary intracranial melanoma is an uncommon entity and only case reports have been published in the literature. We report a case of an elderly male who was operated with a preliminary diagnosis of meningioma, but it proved to be a histological surprise as it came out to be melanoma with no primary anywhere in the body.

Unusual presentation of an intraventricular hydatid cyst as a bleeding cystic tumor: A case report and brief review.

Hydatid cysts constitute only 2% of all intracranial masses, commonly involve parenchyma and very rarely ventricles. Here, we report an unusual case of a primary, isolated intraventricular hydatid cyst that mimicked a tumor and presented as intraventricular hemorrhage with hydrocephalus in a boy, causing a diagnostic dilemma. Although, preoperative modalities like computed tomography, magnetic resonance image and serology generally help in establishing the diagnosis, but hydatid cysts with unusual localizations and atypical imaging findings may complicate the diagnosis and need be considered in the differential diagnosis of all cystic masses in all anatomic locations, especially in endemic areas, so as to reduce the patient morbidity and mortality.

A solitary osteochondroma of the cervical spine: a case report and review of literature.

INTRODUCTION: Osteochondromas are usually found in the extremities and are rarely seen in the spine. They are most commonly found in the posterior elements of the spine, and intraspinal extension is uncommon. Compressive myelopathy as a presentation of vertebral osteochondroma in a child is a rare entity. METHODS: We report a case of vertebral osteochondroma arising from the lamina of C3 vertebra, presenting with features of compressive myelopathyin a 15 year old boy.Total excision of the tumor was carried out along with lamina of C3 vertebra.Patient recovered significantly. CONCLUSION: Spinal osteochondromas must be considered as rare etiology of spinal cord or root compression in the pediatric age group and utmost care should be taken while excising these benign lesions.

Incidence, histopathology, and surgical outcome of tumors of spinal cord, nerve roots, meninges, and vertebral column - Data based on single institutional (Sher-i-Kashmir Institute of Medical Sciences) experience.

CONTEXT: In the absence of a community-based study on the spinal tumors in the Valley, medical records of the only Regional Neurosurgical Center are available. AIM: The aim of this study is to establish a hospital-based regional epidemiology of spinal tumors in the Valley since the data are derived from a single institution. MATERIALS AND METHODS: A retrospective analysis of 531 malignant and nonmalignant tumors of spinal cord, its coverings and vertebrae, which were managed in a Regional Neurosurgical Center under a standard and uniform medical-protocol over 30-year period from 1983 to 2014. RESULTS: The hospital-based incidence for all spinal tumors was 0.24/100,000 persons per year. The malignant spinal cord and vertebral tumors comprised 32.58% (173/531) of all tumors, and benign spinal cord and vertebral tumors comprised 67.42% (358/531). The extradural-intradural tumors such as metastatic lesions and primary malignant vertebral tumors were on rise with 16.38% (87/531) cases. The children below 18 years were 5.46% (29/531), of which 55.17% (16/29) were below 9 years. The most common primary bone malignancy was multiple myeloma (54.54% =12/22). Histopathologically, the most common metastatic deposit in the spinal canal was non-Hodgkin's lymphoma (24.61% =16/65). A mortality of 3.20% (17/531) was noted. Recurrences were noted in 4.90% (26/531), and adjuvant therapies were given to 16.38% (87/531) patients. CONCLUSION: The malignant spinal cord and vertebral tumors, especially metastatic deposits, are on rise in elderly population. The surgical outcome, in terms of recovery and spinal stability, of benign tumors, is comparatively better than malignant ones. The study reveals a low regional incidence (hospital-based) of spinal tumors.

A unique case of calvarial hemangioma.

BACKGROUND: Calvarial hemangiomas are one of the rarest neoplasms affecting the skull, predominantly occurring in parietal and frontal bones. CASE DESCRIPTION: We report a parietal hemangioma in a middle-aged female which presented as a painless swelling that was progressively increasing in size and was treated surgically. CONCLUSION: Although rare, calvarial hemangioma should be a part of the differential diagnosis of calvarial swellings.

Histological-subtypes and anatomical location correlated in meningeal brain tumors (meningiomas).

CONTEXT: Not enough literature is available to suggest a link between the histological subtypes of intracranial meningeal brain tumors, called 'meningiomas' and their location of origin. AIM: The evidence of correlation between the anatomical location of the intracranial meningiomas and the histopathological grades will facilitate specific diagnosis and accurate treatment. MATERIALS AND METHODS: The retrospective study was conducted in a single high-patient-inflow Neurosurgical Center, under a standard and uniform medical protocol, over a period of 30 years from December 1982 to December 2012. The records of all the operated 729 meningiomas were analyzed from the patient files in the Medical Records Department. The biodata, x-rays, angiography, computed tomography (CT) scans, imaging, histopathological reports, and mortality were evaluated and results drawn. RESULTS: The uncommon histopathological types of meningiomas (16.88%) had common locations of origin in the sphenoid ridge, posterior parafalcine, jugular foramen, peritorcular and intraventricular regions, cerebellopontine angle, and tentorial and petroclival areas. The histopathological World Health Organization (WHO) Grade I (Benign Type) meningiomas were noted in 89.30%, WHO Grade II (Atypical Type) in 5.90%, and WHO Grade III (Malignant Type) in 4.80% of all meningiomas. Meningiomas of 64.60% were found in females, 47.32% were in the age group of 41-50 years, and 3.43% meningiomas were found in children. An overall mortality of 6.04% was noted. WHO Grade III (malignant meningiomas) carried a high mortality (25.71%) and the most common sites of meningiomas with high mortality were: The cerebellopontine angles, intraventricular region, sphenoid ridge, tuberculum sellae, and the posterior parafalcine areas. CONCLUSION: The correlation between the histological subtypes and the anatomical location of intracranial meningeal brain tumors, called meningiomas, is evident, but further research is required to establish the link.

Dissociated hypopituitarism after spontaneous pituitary apoplexy in acromegaly.

INTRODUCTION: Pituitary apoplexy is an uncommon event and usually occurs in non-functioning pituitary tumors. Among the functioning tumors, prolactinomas are the ones most likely to apoplexy. Apoplexy in growth hormone (GH) producing adenomas is a very rare event with less than thirty cases reported worldwide. OBJECTIVE: To describe a case of spontaneous pituitary apoplexy in acromegaly. CASE REPORT: A 55 year old smoker male presented to the our outpatient clinic in 2004 with complaints of gradual onset increase in the size of hands and feet, bilateral knee pain, increased sweating and blurring of vision. Investigations uncovered diabetes mellitus by a casual blood glucose of 243 mg/dl and HbA1c of 8.5%. Growth hormone suppression test using 75 gram oral glucose showed a 60 minute growth hormone of 105 ng/ml. Magnetic resonance imaging of the sellar region showed a 12.0 mm × 10.0 mm pituitary adenoma. The patient was planned for transsphenoidal tumor decompression. However, the patient was lost to follow up. Eight-years later, he presented in the emergency department of our institute with sudden onset headache, vomiting and decreased level of consciousness of one day duration. CT scan of the head with focus on the sella was suggestive of apoplexy which was later confirmed by the MRI of the sellar region. CONCLUSION: Although acromegaly can remit following apoplexy of the responsible pituitary adenoma, long term follow up is needed for early detection of the development of deficiency of pituitary hormones which may occur over years following the event as well as to detect tumor regrowth which again may occur several years later.

Bone scintigraphy in Ollier's disease: A rare case report.

Ollier's disease is characterized by multiple skeletal enchondroma. There are published data regarding Ollier's disease being associated with vascular malformations and non-skeletal neoplasms. We report a case of Ollier's disease in a young male associated with osteochondroma, low grade glioma in the insular cortex of brain and Gilbert's syndrome. Technetium-99m methylene diphosphonate whole body bone scan is a sensitive investigation to ascertain the complete extent of skeletal involvement particularly the asymptomatic sites.

Aspiration versus excision: a single center experience of forty-seven patients with brain abscess over 10 years.

The efficacies of two different surgical approaches, aspiration and excision, were investigated for the management of large solitary encapsulated pyogenic brain abscess located in superficial non-eloquent areas, and the impact on length of hospital stay, duration of postoperative antibiotic use, improvement in neurological status, and morbidity and mortality were compared. This retrospective study at Sher-i-Kashmir Institute of Medical Sciences included 47 patients with pyogenic brain abscess from a total of 114 patients evaluated in the Department of Neurosurgery over a period of 10 years from October 2001 to October 2011. Comparisons were made between aspiration and excision in terms of duration of antibiotic use, length of hospital stay, and overall treatment cost. Aspiration was performed in 29 patients (61.7%), of whom 7 patients needed second aspiration, and 18 patients underwent excision (38.3%) of the abscess capsule. The mean duration of antibiotic use in the excision group was significantly shorter at 2.7 weeks (standard deviation [SD]±1.1) compared to the aspiration group at 3.8 weeks (SD±1.3) (p=0.006). Similarly, mean length of hospital stay was significantly shorter in the excision group at 18.1 days (SD±7.7) compared to the aspiration group at 24.9 days (SD±6.6) (p=0.002). In addition, significantly earlier improvement in neurological function (p=0.025) and significantly lower rate of re-surgery (p=0.0238) were found in the excision group compared to the aspiration group. Excision is better than aspiration as far as duration of antibiotic use, length of hospital stay, and overall cost of treatment is concerned, with no significant difference in morbidity and mortality.