Primary Hypothalamic Lymphoma in an Adult Male: A Case Report and Literature Review.

Primary central nervous system lymphoma is a well-known entity. However, the hypothalamus is a rare location, especially in adults. Few cases of secondary lymphomas have been reported. We report a case of primary hypothalamic lymphoma in an adult male with normal pituitary functions. Lymphoma should be considered as one of the differential diagnosis of lesions involving the hypothalamic/third ventricular area.

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.

Supratentorial extraparenchymal schwannoma mimicking parasagittal meningioma: A rare case report.

BACKGROUND: Intracranial schwannomas not related to cranial nerves are very rare. Young age, no known history of neurofibromatosis, and seizure as initial symptom have been reported to be associated with intraparenchymal schwannoma. CASE DESCRIPTION: We report a case of supratentorial parasagittal schwannoma in the right frontal region presenting with seizure episode in a 70-year-old man. Computed tomography and magnetic resonance imaging showed a right frontal solid, enhancing extra-axial lesion based on anterior and middle third junction of superior sagittal sinus. The preoperative diagnosis was right parasagittal meningioma, however, the microscopic examination of the mass showed the characteristic pattern of cellular Antony A pattern. Immunohistocemically, the tumor stained positive for S-100 protein but negatively for epithelial membrane antigen and glial fibrillary acidic protein. These findings are consistent with schwannoma. Cysts, calcification, and peritumoral edema are common in intracerebral schwannoma, which were not seen in our case. CONCLUSION: On the basis of clinical presentation and radiological appearances, schwannoma in unusual sites can easily be mistaken for meningiomas; immunochemistry plays an important role in differentiating them. Till date, to the best of our knowledge, this is the second reported case of schwannoma mimicking meningioma in parasagittal location.

Surgery: Modified Pi with Triple-Bonnet Flap and Fronto-Orbital Advancement.

INTRODUCTION: Craniosynostosis is the premature fusion of one or more of the cranial sutures and can occur as part of a syndrome or as an isolated defect. Pansynostosis is a rare form of craniosynostosis that involves premature fusion of all the cranial sutures (coronal, sagittal, metopic, and occipital). Particularly in cases of late presentation, there are heightened clinical concerns, both functional and aesthetic. In untreated cases of pansynostosis and increased intracranial pressure, optic nerve damage progresses to optic atrophy and then blindness. OBJECTIVES: Cranial vault reconstruction is the standard surgical treatment. We attempt to highlight the importance of modifying the osteotomies and reshaping of the cranial vault based on individual requirements in order to achieve the best possible result and to prevent catastrophic blood loss. METHOD AND RESULTS: We present a case of modified pi with triple-bonnet flap and fronto-orbital advancement, an individual modification of the techniques of cranial vault reconstruction, in a patient with pansynostosis with optic atrophy. CONCLUSION: The technical variation can be applied to any case of pansynostosis requiring cranial vault reconstruction.

Pediatric Head Injury: A Study of 403 Cases in a Tertiary Care Hospital in a Developing Country.

INTRODUCTION: Traumatic brain injury (TBI) in children is a significant cause of morbidity and mortality worldwide. Falls are the most common type of injury, followed by motor vehicle-related accidents and child abuse. AIMS AND OBJECTIVES: The aim and objective of this study was to elucidate the various modes of injury, prognostic factors, complications, incidence of various modes of injury, and outcome in TBI in pediatric population. MATERIALS AND METHODS: Patients with TBI, 18 years or less in age, managed in our Department of Neurosurgery, over a period of 2 years, were studied prospectively. Detailed history, general physical examination, systemic examination, and central nervous system examination including assessment of Glasgow Coma Scale score (GCS) and pupillary size and reaction were noted in every patient. Based on GCS, patients were divided into mild head injury (GCS 13-15), moderate head injury (GCS 9-12), and severe head injury (GCS ≤8) categories. All the patients were subjected to plain computed tomography (CT) scan head, and CT findings were noted. Patients were managed conservatively or surgically as per the standard indications. The outcome of all these patients was assessed by Glasgow outcome scale and divided into good (normal, moderate disability) and poor (severe, vegetative, dead) outcome. Outcome was assessed in relation to age, sex, GCS, pupil size and reaction, CT scan features, intervention, and associated injuries. RESULTS: A total of 403 patients aged between 1 day and 18 years were included in the study comprising 252 males (63%) and 151 females (37.75%). The common modes of injury were fall 228 (56.6%) followed by road traffic accidents 138 (34.2%), assault 10 (2.5%), and others 27 (6.7%) which include sports injury, hit by some object on head, and firearm injury. Majority of our patients had a GCS of 13-15 (mild head injury), 229 (57.3%), followed by 9-12 (moderate head injury) 119 (29.8%), followed by 8 or less (severe head injury) 52 (13%). In group of patients in the category of GCS ≤ 8, poor outcome was seen in 65.3%, followed by patients in group GCS 9-12 at 2.45% succeeded by group of patients with GCS 13-15 at 2.6%, which was statistically significant (P < 0.0001). A total of 354 (87.8%) patients had normal pupils, 37 (9.2%) had anisocoria, and 12 (3%) patients had fixed dilated pupils. Fixed dilated pupil had poor outcome (100%) followed by anisocoria (40.5%) and normal pupils (16%), which was statistically significant (P < 0.0001). CONCLUSION: Majority of children who suffer from TBI do well although it still continues to be a significant cause of morbidity and mortality in them. The outcome is directly related to the neurological status in which they present to the hospital.

Evaluation of hyperglycaemic response to intra-operative dexamethasone administration in patients undergoing elective intracranial surgery: A randomised, prospective study.

BACKGROUND AND AIM: The glucocorticoid dexamethasone in a bolus dose of 8-10 mg followed by quarterly dose of 4 mg is commonly used during intracranial surgery so as to reduce oedema and vascular permeability. However, the detrimental hyperglycaemic effects of dexamethasone may override its potentially beneficial effects. The present prospective, randomised study aimed at comparing the degree and magnitude of hyperglycaemia induced by prophylactic administration of dexamethasone in patients undergoing elective craniotomy. MATERIALS AND METHODS: Sixty American Society of Anaesthesiologist (ASA) grade-I and II patients were randomly assigned to three groups of 20 patients each. Group-I received dexamethasone during surgery for the first time. Group-II received dexamethasone in addition to receiving it pre-operatively, whereas Group-III (control group) patients were administered normal saline as placebo. Baseline blood glucose (BG) was measured in all the three groups before induction of anaesthesia and thereafter after every hour for 4 h and then two-hourly. Besides intra- and intergroup comparison of BG, peak BG concentration was also recorded for each patient. Statistical analysis was carried out with analysis of variance (ANOVA) and Student's t-test and value of P < 0.05 was considered statistically significant. RESULTS: Baseline BG reading were higher and statistically significant in Group-II as compared with Group-I and Group-III (P < 0.05). However, peak BG levels were significantly higher in Group-I than in Group-II and III (P < 0.05). Similarly, the magnitude of change in peak BG was significantly higher in Group-I as compared to Group-II and III (P < 0.05). CONCLUSION: Peri-operative administration of dexamethasone during neurosurgical procedures can cause significant increase in BG concentration especially in patients who receive dexamethasone intra-operatively only.

History of neurosurgery in Sher-I-Kashmir Institute of Medical Sciences.

Sher-i-Kashmir Institute of Medical Sciences (SKIMS) is the only tertiary care institute in the state of Jammu and Kashmir. The department of neurosurgery was established nearly three decades ago and continues to be the leader in providing high quality neurosurgical services in the region. The article provides an insight into the genesis of the department and its sustained growth over these years. It also describes the plans for its future development.

Impact of clinico-radiological parameters on the outcome of treatment in brain tuberculosis.

OBJECTIVES: The Aim of this study was to evaluate the impact of clinico-radiological parameters on the outcome of the treatment in brain tuberculosis. MATERIALS AND METHODS: This study was conducted in the Department of Neurosurgery and Neurology Skims Srinagar India for a period of two years from November 2009 to November 2011. A total of 61 patients presenting with brain tuberculosis admitted at skims during these two years were included in the study. Patients having clinical, laboratory and radiological findings suggestive of brain tuberculosis were included in the study. On correlating the CT characteristics-tuberculomas, basal exudates and hydrocephalus with sequelae at 6,12 and 18 months - focal deficit, cognitive impairment, and diplopia. RESULTS: It was seen that basal exudates correlated with all the three neurological sequelae i.e.; with focal deficit (P = 0.001), cognitive impairment (P = 0.011), and diplopia (P = 0.021). Hydrocephalus correlated well with cognitive impairment (P = 0.031) and tuberculoma correlated with none of these clinical characteristics. CONCLUSION: We concluded that the mortality and neurologic sequelae were directly related to the clinical stage of disease at presentation. Correlating the CT characteristics we concluded that basal exudates correlated with all the three sequelae i.e.; with focal deficit, cognitive impairment, and diplopia. Hydrocephalous correlated well with cognitive impairment and tuberculoma correlated with none of these clinical characteristics.

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.

Management dilemma in penetrating head injuries in comatose patients: Scenario in underdeveloped countries.

BACKGROUND: The optimal management of patients with minimal injury to brain has been a matter of controversy and this is especially intensified when the patient has a poor neurological status. This is important in the regions where neurosurgical services are limited and patient turnover is disproportionate to the available resources. We aimed to determine the effectiveness of aggressive management in coma patients after penetrating missile injuries of the brain. METHODS: All the patients of gunshots or blast injuries were included if they had a Glasgow Coma Scale score of less than 8 after initial resuscitation and had no other injury that could explain their poor neurological status. The indication for emergency surgery was evidence of a mass lesion causing a significant mass effect; otherwise, debridement was done in a delayed fashion. The patients who were not operated were those with irreversible shock or having small intracranial pellets with no significant scalp wounds. The patients who had a Glasgow outcome score of 1, 2, or 3 were classified as having an unfavorable outcome (UO) and those with scores 4 and 5 were classified as having a favorable outcome (FO). RESULTS: We operated 13 patients and the rest 13 were managed conservatively. The characteristics of the patients having a favorable outcome were young age (OR = 28, P = 0 .031), normal hemodynamic status (OR = 18, P = 0.08), presence of pupillary reaction (OR = 9.7, P = 0.1), and injury restricted to one hemisphere only (OR = 15, P = 0.07). All of the patients who were in shock after resuscitation died while 25% of the patients with a normal hemodynamic status had a favorable outcome. CONCLUSIONS: In developing countries with limited resources, the patients who are in a comatose condition after sustaining penetrating missile injuries should not be managed aggressively if associated with bihemispheric damage, irreversible shock, or bilateral dilated nonreacting pupils. This is especially important in the event of receiving numerous patients with the same kind of injuries.

Elevated skull fractures in pediatric age group: report of two cases.

Elevated fractures of the skull, which are rarely reported in the literature, are always compound, have maximal neurological deficits at presentation and have been reported only in adults. We report two cases of elevated skull fractures in the pediatric age group, one of which was a simple elevated fracture and presented with delayed neurological deterioration. The etiologies were a fall in first case and an animal attack (bear maul) in the second case as reported for the first time. One of the cases presented with delayed onset of left focal hemispheric signs. The first case underwent debridement, duraplasty and reduction of fracture whereas in the second case the bone flap was not replaced immediately because of gross contamination. Both patients had an excellent outcome. Elevated skull fractures are not uncommon in the pediatric age group. Compound elevated skull fractures should be managed early as open depressed fractures. Reduction of a simple elevated fracture presenting with neurological deficits not explained by any other lesion can result in a good outcome.