A Prospective, Randomized, Interventional Study of Oral Iron Supplementation Comparing Daily Dose with Alternate Day Regimen Using Hepcidin as a Biomarker in Iron Deficiency Anemia.

AIM: To assess effect of daily vis-a-vis alternate day oral iron therapy in terms of hemoglobin, reticulocyte hemoglobin equivalent (RET-He) and GI side effects using hepcidin as a biomarker. METHODS: A hospital based randomized interventional two-arm analytical study was done among patients of IDA (20 in each group). The study population was divided into two groups by randomisation. Group 1 received oral iron supplements on alternate day and Group 2 received iron supplements daily. Hemoglobin, RET-He, Serum ferritin and Hepcidin level were assessed. RESULTS: On day 2nd, the rise in Hepcidin was not significant from base line in alternate day therapy group but was significantly increased in daily therapy group. On day 3, the rise in hepcidin was significant from base line in both the groups but the mean change in hepcidin was more in daily therapy group. RET-He began increasing on day 2nd in both the groups. In alternate day therapy group, the rise in RET-He was significant from base line from the day 2nd onwards while the rise in RET-He in daily therapy group was not significant even on day 3. In alternate day iron therapy group, the mean increase in hemoglobin on day 21th (1.58 ±0.53 gm/dl) was significantly more than mean increase among daily therapy (0.41 ± 0.25 gm/dl, P <0.05). CONCLUSION: Alternate day single tablet dosing schedule of oral iron therapy (60mg of elemental iron, ferrous sulfate) was more effective and better tolerated (gastrointestinal side effects) compared to daily supplementation in IDA.

Low Dose Prophylaxis vis-a-vis on-Demand Treatment Strategies for Hemophilia: A Cost Effective and Disability Attenuating Approach.

AIM: To assess effect of low dose prophylaxis in hemophilics in terms of bleeding, joint function, QoL and cost-effectiveness. METHODS: Analytic study done during one year among 70 adult hemophilics. In observation period (12 weeks), on-demand factor and during prophylaxis (12 weeks), low dose factor was given (Factor VIII 10 IU/KgBW biweekly for haemophilia A and Factor IX 20 IU/KgBW weekly for haemophilia B). Clinical joint assessment was done by Gilbert score and improvement by WFH definitions. RESULTS: Bleed reduced by 68.99% in moderate hemophilics (40 v/s 129) and 64.86% in severe hemophilics (26 v/s74) (p<0.05). During observation in moderate hemophilics, joint, soft tissue and mucosal bleeds occurred in frequency of 120, 1 and 8. This was reduced to 39 joint bleeds, 1 soft tissue bleed and no mucosal bleed during prophylaxis. In severe hemophilics, 70 joint, 2 soft tissue bleeds and 2 mucosal bleeds occurred during observation which reduced to 26 joint bleeds without soft tissue/mucosal bleed in prophylaxis. Bleeding episodes decreased by 65.79% in joints, 66.67% in soft tissues, 100% mucosal bleeds. After prophylaxis one joints (0.61 %) showed good improvement in joint function, thirty (18.18 %) joints showed moderate improvement and ninety two joints (55.76 %) showed mild improvement in joint function. Hospitalization reduced by 60.34% (163 v/s 411) and absenteeism by 53.73% (279 v/s 603). Factors consumption reduced by 12.33 % during prophylaxis period. CONCLUSION: The low dose prophylaxis strategy significantly decreased the subsequent episodes of total bleeds including joint bleeds and improved the joint function as well as quality of life.

Genome-wide ChIP-seq analysis of EZH2-mediated H3K27me3 target gene profile highlights differences between low- and high-grade astrocytic tumors.

Enhancer of zeste homolog-2(EZH2) is a key epigenetic regulator that functions as oncogene and also known for inducing altered trimethylation of histone at lysine-27 (H3K27me3) mark in various tumors. However, H3K27me3 targets and their precise relationship with gene expression are largely unknown in astrocytic tumors. In this study, we checked EZH2 messenger RNA and protein expression in 90 astrocytic tumors of different grades using quantitative PCR and immunohistochemistry, respectively. Further, genome-wide ChIP-seq analysis for H3K27me3 modification was also performed on 11 glioblastomas (GBMs) and 2 diffuse astrocytoma (DA) samples. Our results showed EZH2 to be highly overexpressed in astrocytic tumors with a significant positive correlation with grade. Interestingly, ChIP-seq mapping revealed distinct differences in genes and pathways targeted by these H3K27me3 modifications between GBM versus DA. Neuroactive ligand receptor pathway was found most enriched in GBM (P = 9.4 × 10-25), whereas DA were found to be enriched in metabolic pathways. Also, GBM showed a higher enrichment of H3K27me3 targets reported in embryonic stem cells and glioma stem cells as compared with DAs. Our results show majority of these H3K27me3 target genes were downregulated, not only due to H3K27me3 modification but also due to concomitant DNA methylation. Further, H3K27me3 modification-associated gene silencing was not restricted to promoter but also present in gene body and transcription start site regions. To the best of our knowledge, this is the first high-resolution genome-wide mapping of H3K27me3 modification in adult astrocytic primary tissue samples of human, highlighting the differences between grades. Interestingly, we identified SLC25A23 as important target of H3K27me3 modification, which was downregulated in GBM and its low expression was associated with poor prognosis in GBMs.

Study of ß-catenin and BRAF alterations in adamantinomatous and papillary craniopharyngiomas: mutation analysis with immunohistochemical correlation in 54 cases.

Craniopharyngiomas (CP) are rare benign epithelial tumors, with two histological variants, namely the adamantinomatous variant (ACP) and the rarer papillary variant (PCP). They are locally infiltrative and surgically challenging tumors with severe long term morbidity. CTNNB1 mutations with ß-catenin immunopositivity and BRAFV600E mutations with anti-VE immunopositivity have been recently described in ACPs and PCPs respectively. We aimed to study BRAF and CTNNB1 gene mutations in CPs operated at our institute, and correlate it with clinicopathological parameters including histopathology and immunohistochemistry (IHC) for proteins VE-1 and ß-catenin. A total of 54 CPs diagnosed over 3-year duration were included. IHC for ß-catenin and VE-1 proteins, and Sanger sequencing for CTNNB1 (exon 3) and BRAF (exon 15) genes were performed. CTNNB1 mutations were identified in 63% (27/43) of ACPs while nuclear immunopositivity for ß-catenin was observed in 79% (34/43) of them. Seven ACPs showed ß-catenin immunopositivity in the absence of mutations. BRAFV600E (p.Val600Glu) mutations were observed in 57% of PCPs (4/7), while cytoplasmic immunopositivity for anti-VE1 antibody was observed only in 43% of PCPs (3/7), all of which also harboured BRAFV600E mutations. The mutations and IHC staining patterns of ACPs and PCPs were non-overlapping. Four cases with uncertain histological pattern could be subcategorised into specific variants only following mutation analysis/IHC. The identification of hallmark molecular signatures in the two CP variants holds promise for alternate improved treatment modalities, emphasizing the need for sub-categorization in routine histopathology reporting. IHC for ß-catenin and targeted sequencing for BRAFV600E serve as useful adjuncts.

Spinal arachnoid cysts - our experience and review of literature.

OBJECTIVE: Arachnoid cysts are discrete pockets of CSF or CSF-like fluid found adjacent to normal CSF spaces, either spinal or cranial. Spinal arachnoid cysts (SAC) are most commonly extradural, however intradural or perineural are also described. METHODS: All patients admitted to our center and surgically treated with a diagnosis of SAC, were included in the study. The results were analyzed in terms of the clinical symptoms, location of cyst, surgical procedure performed and outcome following surgery. RESULTS: Eleven patients were operated for SAC during the study period and the mean age at surgery was 32.9 ± 20.8 years. Male to female ratio was 2.7:1 in our series. Common presenting complaints were lower limb weakness and pain. The median duration of symptoms before surgery was nine months (mean 21 ± 28 months). Ten patients had extradural cysts while one had intradural cyst. Extradural cysts were managed by laminoplasty and excision of the cyst, except for one patient in whom the SAC extended from C3 to L2 and marsupialization of the cyst was done. The only patient with intradural cyst underwent cyst fenestration. One patient had two communications and both were closed. In our series, at the time of last follow up two patients became completely free of symptoms, while other five reported substantial improvement in their symptoms. Operative complications were noted in two patients. CONCLUSION: Formation and expansion of SAC is not completely understood. Myelography, CT myelography and cinematic MRI can demonstrate the location of the communication site between the spinal subarachnoid space and the cyst cavity. The usual management of SAC is excision of the cyst with closure of the dural defect in extradural cysts, while in case of intradural cysts, especially the ones located anterior to the cord, fenestration of the cyst is usually performed.

A randomized placebo-controlled trial of progesterone with or without hypothermia in patients with acute severe traumatic brain injury.

OBJECTIVE: Among newer neuroprotectant modalities, hypothermia and progesterone have shown a beneficial role in preliminary studies enrolling patients with severe traumatic brain injury (sTBI). The primary objective of this study was to evaluate the efficacy of progesterone with or without prophylactic hypothermia in acute sTBI patients. MATERIALS AND METHODS: This is a prospective, outcome assessor, statistician blinded, randomized, and placebo-controlled phase II trial of progesterone with or without hypothermia (factorial design). All adult patients (18-65 years) with acute sTBI (Glasgow coma score of 4-8) and presenting to trauma center within 8 h after injury were included in the trial. Computer-generated randomization was done after exclusion; sequentially numbered, opaque, sealed envelope technique was used for allocation concealment. The enrollment duration was from January 2012 to October 2014. The primary endpoint was dichotomized Glasgow outcome score (GOS) [poor recovery = GOS 1-3; good recovery = GOS 4-5], and secondary endpoints were functional independence measure (FIM) score and mortality rate at 6 and 12 months follow-up after recruitment. RESULTS: A total of 107 patients were randomized into four groups (placebo [n = 27], progesterone [n = 26], hypothermia alone [n = 27], and progesterone + hypothermia [n = 27]). The study groups were comparable in baseline parameters except for a higher incidence of decompressive craniectomy in the placebo group (P = 0.001). The analysis of GOS at 6 months revealed statistically significant better outcome in the hypothermia group (82%; P = 0.01) and a weaker evidence for progesterone group (74%; P = 0.07) as compared with the placebo group (44%). However, the outcome benefit was marginal at 1-year follow-up for the hypothermia group (82% vs. 58%, P = 0.17). The adjusted odds ratio of poor recovery at 6 months in the hypothermia group was 0.21 (confidence interval = 0.05-0.84, P = 0.03), as compared with the placebo group. Although mean FIM scores at 6 and 12 months respectively were marginally higher in the hypothermia and progesterone groups compared with the placebo group (P = 0.06 and 0.27), the proportion of functionally independent individuals were similar in all the groups (P = 0.79 and 0.51). The mortality rates were similar in all the groups at 6 and 12 months (P = 0.78 and 0.52 respectively). CONCLUSIONS: A strong evidence for prophylactic hypothermia and a weak evidence for progesterone therapy was observed for a better primary outcome at 6 months as compared to the placebo. A similar trend was observed at a 1-year follow-up. Contrary to our hypothesis, prophylactic hypothermia therapy suppressed the beneficial effects of progesterone therapy in sTBI patients. The complex cascades of factors responsible for such interactions are still unknown and need to be further determined.

Neuroblastoma-like schwannoma of the skull base: an enigmatic peripheral nerve sheath tumor variant.

Neuroblastoma-like schwannoma is an extremely rare histological variant of schwannoma, which histologically mimics a malignant small round cell tumor. Only 19 cases have been reported in the literature to date. We report a case of this tumor located at the skull base in a 44-year-old woman who presented with symptoms of right-sided earache and hearing loss. MRI revealed a large, lobulated, extra-axial mass measuring 8.8 cm × 3.6 cm × 4.2 cm in the floor of the middle and posterior cranial fossa. Microscopic examination revealed a perplexing histopathology with peculiar collagenous rosettes. Differential diagnoses included a broad range of benign and malignant tumors. Typical schwannoma seldom poses a difficulty in diagnosis; however, this unusual variant is a diagnostic challenge which requires an extensive clinico-radiological correlation and immunohistochemical work-up. Hence, knowledge of this entity is a must to avoid erroneous diagnosis and inappropriate treatment.

Management of pediatric single-level vertebral hemangiomas presenting with myelopathy by three-pronged approach (ethanol embolization, laminectomy, and instrumentation): a single-institute experience.

PURPOSE: Pediatric vertebral hemangiomas (VH) are exceedingly rare benign and highly vascular tumours of the spine. There are no guidelines available for management of these patients in literature. Purpose of this study is to evaluate the role of intraoperative ethanol embolization, surgical decompression, and instrumented fusion in pediatric symptomatic VH with single-level involvement. METHODS: Surgery consisted of intraoperative bilateral pedicular absolute alcohol injection and laminectomy at the level of pathology followed by a short-/long-segment instrumented fusion using pedicle screws and rod. Seven patients (mean age 14 ± 2.4 years, range 10-17 years, five females and two males) (age < 18 years) who were treated using this technique at our institute since March 2008 to December 2013 were enrolled in this retrospective study. Demographical, clinical, radiological, operative details, and postoperative events were retrieved from hospital records. During follow-up visits, clinical status and imaging were recorded. Outcome assessed with clinical and neurological outcome score of American Spinal Injury Association (ASIA) Impairment Scale. RESULTS: Duration of symptoms ranged from 3 to 60 months (mean, 14.7 ± 20.4 months). Clinical features include myelopathy with motor and sensory involvement in all (five were paraplegic), back pain in two patients, and bladder involvement in two patients. The preoperative American Spinal Injury Association (ASIA) Impairment Scale (AIS) were B in five patients and C and D in one patient each. All had pan vertebral body VH with severe cord compression in the thoracic region on imaging study. Mean duration of surgery was 248.6 ± 60 minutes (range 195-310 min) and blood loss was 535 ml (range 200-1500 ml). Immediate embolization was achieved in all patients, which allowed laminectomy and soft tissue hemangioma removal relatively easy. Post surgery, at mean follow-up of 45.3 (±23.2) months (range 1-78 months), all patients showed improvement in power (sphincter improvement in two patients). ASIA were E in six patients and D in one patient at the last follow-up. CONCLUSION: The present study is the largest series of pediatric symptomatic VH. This procedure is a safe, efficient method to treat symptomatic pediatric VH with severe cord compression. It seems to serve the purpose of providing embolization, cord decompression, rigid fusion at the same sitting without adding new morbidity, and preventing excessive blood loss.

Ventral foramen magnum neurenteric cysts: a case series and review of literature.

Neurenteric cysts (NEC) are uncommon, benign, congenital lesions. Ventral foramen magnum (FM) location is very rare. The difficulties in diagnosis and management aspects are detailed with a review of the pertinent literature. We report four new cases of ventral FM NEC, all managed surgically and present a literature review of ventral FM NEC. A retrospective analysis of histopathologically confirmed cases of ventral FM NEC, operated from 2010-2013 at our institute, was performed. For review, only those cases of NEC extending from the lower clivus to the C2 level constituting the foramen magnum were included. Including our four cases, a total of 47 cases were identified. The male to female ratio was 1.2:1. Mean age was 33.5 years (range 1-60 years). Neck pain and occipital headache were the most common symptoms, followed by limb weakness and cranial nerve paresis. Recurrent meningitis was noted in three cases. Hyperintensity on both T1- and T2-weighted sequences with absent enhancement was the most common finding on MRI. Surgical approaches were as follows: suboccipital (n = 21), far/extreme lateral (n = 18), retrosigmoid (n = 6), and transoral (n = 4). The extent of resection was as follows: total, 26; near total, 6; subtotal, 9; and partial, 3 cases. Cerebrospinal fluid diversion was done in four cases for intracranial hypertension. Mean follow-up duration was 26.8 months (range 1 month-9 years). Recurrence was noted in four (8.5 %) cases. One (2 %) case had malignant transformation. Mortality rate was 4 %. Foramen magnum neurenteric cysts are rare, benign tumors of the central nervous system. Accurate preoperative diagnosis can often be established with MRI. Surgical removal is the treatment of choice. Complete excision is ideal but often not possible. Near total removal would suffice with good progression-free periods. A long-term follow-up with radiological studies is necessary as delayed recurrences can occur.

Prediction of facial nerve position in large vestibular schwannomas using diffusion tensor imaging tractography and its intraoperative correlation.

OBJECTIVE: Resection of large Vestibular Schwannomas (VSs) can be associated with postoperative facial nerve injury. Diffusion-based tractography has emerged as a powerful tool for three-dimensional imaging and reconstruction of white matter fibers; however, tractography of the cranial nerves has not been well studied. In this prospective study, we aim to predict the position of facial nerve in large VSs (>3 cm) using Diffusion Tensor Imaging (DTI) tractography and correlate it with the intraoperative finding of the position of facial nerve. MATERIALS AND METHODS: Twenty patients with a large VS (>3 cm) undergoing surgery were subjected to preoperative DTI to predict the position of the facial nerve in relation to the tumor. The surgeon was blinded to the results of the preoperative DTI tractography. A comparative analysis was then made during operation. The location of the facial nerve in relation to the tumor was recorded during surgery using facial nerve stimulator. RESULTS: Of the 20 patients who underwent DTI tractography, it was not possible to preoperatively identify facial nerve in one patient. In another patient, although DTI tractography predicted the position of facial nerve, it was not identified intraoperatively. In the remaining 18 patients, DTI tractography accurately predicted the facial nerve position. The predicted position was in synchronization with the intraoperative facial nerve position in 16 patients (89% concordance). It was discordant in two patients (11%), but this was not found to be statistically significant (P = -0.3679). CONCLUSION: This study validates the reliability of facial nerve DTI-based fiber tracking for prediction of the facial nerve position in patients with large VSs. The reliable preoperative visualization of facial nerve location in relation to the VS will allow surgeons to plan tumor removal accordingly and may increase the safety of surgery.

Medial sphenoid wing meningiomas: Experience with microsurgical resection over 5 years and a review of literature.

BACKGROUND: Medial sphenoid wing meningiomas are medially located tumors on the sphenoid wing with attachment over the anterior clinoid process. They represent a distinct entity. These medial sphenoid wing meningiomas present a more difficult problem for the neurosurgeons because in a majority of cases, they involve the anterior visual pathways and arteries of the anterior circulation and may invade the cavernous sinus (CS). Higher morbidity, mortality and recurrence rates have been observed in these tumors compared with meningiomas in other locations. The rate of recurrence for medial sphenoid wing meningiomas is reported as being one of the highest amongst intracranial meningiomas. MATERIAL AND METHODS: The authors retrospectively analyzed 78 consecutive patients with the diagnosis of medial sphenoid wing meningioma who were operated in our department from January 2008 to December 2012. RESULTS: These patients, having a meningioma of the medial sphenoid ridge, were divided into two types depending on the involvement of CS. Diplopia, internal carotid artery encasement, and postoperative visual deterioration were more common in Type 2 tumors. Similarly, extent of resection and postoperative morbidity were greater in Type 2 patients. CONCLUSIONS: CS invasion confers an added risk to the surgical morbidity and outcomes. However, with proper surgical techniques, optimum outcomes can be achieved and overall surgical results at our center are found to be comparable to that of the current literature.

Surgical results of growing skull fractures in children: a single centre study of 43 cases.

PURPOSE: Growing skull fractures are rare complications of traumatic skull fractures in children. The authors aim to share their experience in management of such lesions and analyse clinicoradiological features, surgical management and outcome in addition to prognostication factors. MATERIALS AND METHODS: Retrospective study performed to include patients ≤18 years operated for growing skull fractures at our trauma centre from December 2007 to February 2014. RESULTS: Forty-three children were operated. Mean age at presentation was 4.57 years (range 7 months-18 years). Mean duration of onset of symptoms from initial trauma was 3.34 months (2 days-24 months). Mean interval from symptom onset to surgical repair was 11.6 months (1 week-15 years). Progressive non-tender scalp swelling was the most common symptom and parietal, the most common location. Duraplasty alone was performed in four patients while combined duro-cranioplasty was performed in the rest. Mean follow-up duration was 31 months (4-72 months). Subdural hygroma was associated in six cases. Two patients expired; rest all survivors had good-to-excellent cosmetic outcomes. CONCLUSIONS: Being the second largest series to date, it adds significant valuable contribution to this topic. Poor prognostic factors were age >8 years, females, large defects (>7 cm), severe head injury at initial trauma, defects crossing midline and delayed repair (>8 months). Delayed onset seizures and new onset/progression of pre-existing deficits can be indirect markers of evolution. Surgical repair with water-tight dural closure is the standard treatment. Emphasis on early treatment is highlighted which is probably beneficial in improving neurological deficits. Good-to-excellent outcomes are noted in majority, even in cases with delayed presentations.

Spinal hemangiopericytoma: an institutional experience and review of literature.

PURPOSE: Hemangiopericytoma is a rare tumor of CNS with potential for recurrence and widespread metastasis, even outside CNS with even rare involvement of spinal cord. This case series presents five patients to evaluate the clinical presentation, radiological features, management, pathology and outcome of spinal hemangiopericytomas. METHODS: Between 2004 and 2013, five patients underwent surgery for spinal hemangiopericytoma. Histopathological data were reviewed in all cases and clinical and follow-up details were collected from the data available in our department. RESULTS: There were three males and two females, including one pediatric patient. Three patients had dorsal spine involvement and two patients had involvement of cervical spine. There were two patients with intradural extramedullary tumors, one patient each with pure intramedullary tumor, pure extradural tumor and both intra and extradural tumor. All of them presented with motor weakness. Gross total resection of the tumor was done in three patients. Four patients received post-operative radiotherapy. Histopathology showed anaplastic tumor in four cases with high MIB-1 LI. Most of them were positive for CD34, mic-2 and bcl-2. Three patients who underwent gross total resection improved significantly in the follow-up period. Two patients who underwent subtotal resection expired due to spread of their disease. CONCLUSION: Spinal hemangiopericytoma is a rare tumor. Strong clinical suspicion is required to diagnose it pre-operatively. Gross total resection is the goal and radiotherapy should be given in case of residual tumor or high-grade tumors.

Surgical results of decompressive craniectomy in very young children: A level one trauma centre experience from India.

INTRODUCTION: Literature remains sparse regarding decompressive craniectomy (DC) in traumatic brain injury (TBI) in very young children. This study analysed the indications, complications and outcome of young children undergoing DC for TBI at our institute. STUDY DESIGN: Retrospective. OBSERVATIONS: The total number of patients was 71. Mean age was 1.6 years. Mean duration from injury to surgery was 11.9 hours (range = 3-80 hours). Around 50% had severe head injury. Intracranial pressure (ICP) monitoring was done in 33 patients. Mean ICP was 22.2 mm Hg (range = 9-50 mm Hg). The threshold ICP for surgery was 15 mm Hg. Perioperative mortality was 50% each for severe TBI (18/36) and diffuse cerebral edema (7/14), and 58% for infants (4/7). Ninety per cent of expired patients had ICP > 20 mm Hg. Mean follow-up duration was 19.6 months (range = 2-42 months). Except one, all survivors had good-to-excellent outcomes (Glasgow outcome scale extended; GOS-E = 7-8). CONCLUSIONS: Decompressive craniectomy offers a survival advantage in almost 50% of young children with severe TBI and should be used judiciously. The highest mortality was within the 1st week of surgery. The cut-off limit of 20 mm Hg for surgical decompression might not be applicable to young children and a low threshold ICP needs to be considered. Factors associated with increased mortality are high opening ICP (>20 mm Hg), GCS <8, diffuse cerebral oedema and infant age group. Timing of DC remains crucial. Further prospective studies are necessary to optimize the timing and ICP limit for surgical decompression.

Traumatic Pediatric Posterior Fossa Extradural Hematomas: A Tertiary-Care Trauma Center Experience from India.

INTRODUCTION: Traumatic posterior fossa extradural hematomas (PFEDH) are rare lesions constituting <10% of all extradural hematomas. Reliance on clinical findings alone is not recommended as these are nonspecific; for all suspicious cases, it is advisable to conduct a CT scan. Only a handful of pediatric studies have been reported analyzing the outcome of such lesions. The aim of our study was to analyze outcomes for children with PFEDH managed at our apex trauma center. MATERIALS AND METHODS: We conducted a retrospective analysis of pediatric patients (≤18 years) admitted with a diagnosis of traumatic PFEDH from January 2008 to February 2014. RESULTS: Of 22 patients, 16 were managed surgically (group 1) and 6 conservatively (group 2); 1 failed conservative treatment (due to an increased EDH volume). Mean age was 11.7 years (range 2-18 years). Falls were the most common cause of injury. Vomiting and loss of consciousness were the most frequent presenting features. There were 18 mild, 2 moderate and 2 severe head injuries. The mean volume of EDH was 37.1 ml (range 18-100 ml) and 10.3 ml (8-16 ml) in the operative and conservative subgroups, respectively. Occipital bone fracture was seen in 16 cases with supratentorial extension in 11. Four complications were noted in 3 cases. Mean follow-up duration was 25.1 months (range 3-34 months). Except for 1 patient, all had excellent outcomes. There was no mortality. CONCLUSIONS: Traumatic pediatric PFEDHs are rare. Both the clinical status of the patient and the volume of the hematoma need to be assessed before deciding on surgery. Most cases have associated occipital bone fractures and around half have supratentorial extension; these need to be carefully assessed preoperatively. Torrential venous bleeding can be a major problem due to rupture of the adjacent sinuses. Timely intervention is crucial for achieving good outcome, keeping in view a low threshold for surgical evacuation. Although not innovative, this second-largest case series provides additional data and contributes to the existing literature on such lesions in pediatric patients.

Quadrigeminal cistern arachnoid cyst: A series of 18 patients and a review of literature.

BACKGROUND: Arachnoid cysts account for 1% of intracranial mass lesions. Quadrigeminal cistern arachnoid cysts are even rarer lesions. We report 18 cases of quadrigeminal cistern arachnoid cysts treated at our institute from 2002 to 2012. METHODS: We retrospectively analysed 18 patients with quadrigeminal cistern arachnoid cyst for clinical presentation, demographic profile, management and outcome. The age of the patients ranged from 29 days to 50 years (mean 17 years). The cysts were classified into 3 subtypes based on MRI findings. Surgical intervention was carried out in all the patients. RESULTS: Two patients had Type 1 cysts, 4 had Type 2 cysts and 12 had Type 3 cysts. Two patients (Type 1) underwent endoscopic third ventriculostomy (alone). Craniotomy and cyst wall excision along with ventriculocystostomy and cystocisternostomy were done in 4 patients with Type 2 cysts, and endoscopic fenestration of cysts to the sub-arachnoid space or the ventricles and endoscopic third ventriculostomy were done in 7 patients with Type 3 cysts. Two patients with Type 3 cysts underwent only endoscopic ventriculocystostomy and cystocisternostomy without endoscopic third ventriculostomy, while three patients underwent ventriculoperitoneal shunt. The follow- up period ranged from 6 months to 48 months (mean 23.7 ± 12.3 months). CONCLUSION: Quadrigeminal plate arachnoid cysts are generally symptomatic and require some form of surgical intervention. We believe that endoscopic fenestration of the cyst with cystocisternostomy or cystoventriculostomy, when combined with third ventriculostomy, is the procedure of choice for such patients. We do not recommend the placement of a ventriculoperitnoeal shunt alone. Operative re-exploration should be planned only after obtaining proper clinico-radiological correlation and not on the basis of imaging findings alone, as sometimes the cysts fail to regress but the symptoms improve.

Transorbital penetrating cerebral injury caused by a wooden stick: surgical nuances for removal of a foreign body lodged in cavernous sinus.

PURPOSE: Penetrating head injury (PHI) is rare in civilian population and is mostly caused by low-velocity modes. A transorbital penetrating intracranial injury is very rare and more severe than traumatic brain injury. METHODS: We report a rare case of transorbital penetrating cranial injury caused by a wooden stick. The surgical strategy was planned as the wooden stick was lodged in the right cavernous sinus. RESULTS: The wooden stick was successfully removed. Patient made an uneventful recovery. CONCLUSIONS: Transorbital penetrating injuries are uncommon form of injury and require a multidisciplinary approach. No attempt should be made to remove the foreign body without the backup of an operating room because of the possibility that the object may be tamponading an injured vessel. A careful planning and a strict adherence to basic perioperative principles can lead to a satisfactory outcome.

Microsurgical outcome in posttraumatic brachial plexus injuries in children.

PURPOSE: The purpose of the study was to analyze the surgical outcomes in children (≤18 years) with brachial plexus injury operated between April 2008 and March 2012 at our center. METHODS: All children <18 years of age admitted to our center and surgically treated with a diagnosis of posttraumatic brachial plexus injury were included in the study. The demographic details of these patients were retrieved from the computerized database of our hospital. The results were analyzed in terms of the mode of injury, type of injury, surgical procedure performed, and motor recovery after the surgery (MRC Grading). Motor recovery with MRC >3/5 was termed as good outcome. OBSERVATIONS: A total of 33 patients were surgically treated. The mean age at presentation was 15.1 (range 4-18) years. Boys constituted 79% (n = 26) of our patient population. High-velocity injury was the commonest mode of injury. Panbrachial injury was the commonest seen in 82% (n = 27) of patients. Mean duration between injury and surgical intervention was 6 (range 2-13, SD ± 2.6) months. Majority of patients underwent neurotization procedure. Mean follow-up was 32 (range 6-51) months. CONCLUSIONS: High-velocity trauma is the most common mode on injury. Global palsy involving all the plexal elements was present in 82% of the children. Neurotization was the most commonly performed surgical procedure. Good motor outcome (MRC grade ≥3/5) was seen in 62% of patients.

Pediatric intracranial aneurysms--our experience and review of literature.

PURPOSE: Intracranial aneurysms in children are not as common as in adults and there are many differences in the etiology, demographic variables, aneurysm location, aneurysm morphological characteristics, clinical presentation, and outcome in pediatric and adult intracranial aneurysms. METHODS: All children (≤18 years) suffering from intracranial aneurysm managed at our center from July 2001 through June 2013 were included in the study, and the details of these patients were retrieved from the computerized database of our hospital. OBSERVATIONS: A total of 62 pediatric patients were treated for 74 aneurysms during the study period and constituted 2.3% of all intracranial aneurysms treated during the same period. The mean age at presentation was 13.5 years. Headache (82%) was the commonest presenting feature; other symptoms included seizures (21%), ictal loss of consciousness (27%), and motor/cranial nerve deficits (22.6%). Computed tomogram revealed subarachnoid hemorrhage in 58% of patients. Eighty-two percent of aneurysms were in anterior circulation. Sixty-seven percent of aneurysms were complex aneurysms. Fifty-eight percent of patients underwent surgical intervention while 30% underwent endovascular procedures. Twenty-one percent of the patients developed vasospasm. There was no postoperative mortality. Favorable outcome was seen in 72% of the patients. CONCLUSIONS: Pediatric intracranial aneurysms are uncommon as compared to in adult patients. Seizures and cranial nerve involvement are seen more often as the presenting features in children. Posterior circulation aneurysms are more common in children, as are the internal carotid artery bifurcation aneurysms. There is high incidence of giant, posttraumatic, and mycotic aneurysms in children.

Bilateral abducens nerve palsy associated with subarachnoid hemorrhage.

OBJECTIVE: Isolated abducens nerve palsies associated with intracranial aneurysms have rarely been reported. The purpose of the study was to study the patients with bilateral abducens nerve palsy in association with subarachnoid hemorrhage (SAH). METHODS: All patients admitted and managed at our center with a diagnosis of SAH and had bilateral abducens nerve palsy were included in the study. The demographic and clinical details, radiological findings, treatment data, and outcome of these patients were retrieved from the computerized database of our hospital. RESULTS: Nine patients, with a mean age of 49.4 years, met the inclusion criteria. Male to female ratio of 1.25:1). Average duration of symptoms before presentation was 2.6 days (ranging from 1 to 4 days). Third nerve palsy in addition to bilateral abducens nerve palsy was present in 4 patients (44%). DSA demonstrated aneurysms in 7 patients; 4 had posterior circulation aneurysms and 3 had aneurysms of anterior circulation. Two patients had angionegative SAH. The abnormality resolved in all but one patient over a time period of 4-9 weeks, and one patient died due to unrelated cause. CONCLUSIONS: Bilateral abducens nerve palsy in association with SAH is rarely described. Proposed mechanisms include direct compression of the bilateral abducens nerves, vasospasm of the pontine branches of the basilar artery and hydrocephalous. Most of the patients in our series showed resolution of the symptoms over a period of 4-9 weeks.