Post myocardial infarction left ventricular intramural dissecting hematoma: a case report describing a very rare complication.

BACKGROUND: Dissecting intramural hematoma is a rare complication of acute myocardial infarction (AMI) and has been associated with increased mortality. There has been paucity of literature to establish protocols and guidelines for management in such cases. CASE PRESENTATION: We hereby report the case of a 45-year-old male patient with left ventricular intramural dissecting hematoma (LV-IDH) who presented with chest pain and breathlessness and diagnosed as non-ST-elevation myocardial infarction (NSTEMI). Transthoracic echocardiography (TTE) was performed showing LV-IDH, confirmed with cardiac magnetic resonant imaging (cMRI). Selective coronary arteriography (CAG) was performed showing significant obstructive coronary artery disease (CAD). Further management with conservative approach involved discussion with patient, cardiothoracic surgeon and cardiology team including heart failure specialist and interventional cardiology. CONCLUSIONS: This case describes a rare complication of AMI and also focuses on utility of TTE and cMRI in the diagnosis of this rare complication. Both diagnosis and management are challenging and have to be individualized in similar cases. Multidisciplinary care coordination is important in management of patients with this diagnosis.

Efficacy of antimicrobial medicated ventricular catheters: a network meta-analysis with trial sequential analysis.

There is paucity of evidence regarding relative performance of antibiotic-medicated (AM), silver-medicated (SM) and non-medicated (NM) ventricular catheters in controlling infection rate. We aim to quantitatively synthesize the current evidence after addition of the three-armed British Antibiotic and Silver Impregnated Catheters for ventriculoperitoneal Shunts (BASICS) trial, understand the need for further evidence using trial sequential analysis (TSA) and incorporate the indirect evidence using network meta-analysis (NMA). Randomized controlled trials (RCTs) comparing AM, SM and NM ventriculoperitoneal shunt (VPS) or external ventricular drain (EVD) were included. Antibiotic-medicated VPS show a significantly lower infection rate as compared to non-medicated VPS (RR 0.44; 95% CI: 0.27-0.73; p = 0.001), however, TSA reveals need for further evidence. SM including both EVD as well as VPS were found to be inferior to AM while no significant difference was found in comparison to the NM catheters. In NMA for VPS, the AM were found to be significantly better than SM (RR 0.41, 95% CI: 0.22-0.75) as well as NM (RR 0.42; 95% CI: 0.25-0.71) with a SUCRA of 99.8% and a mean rank of 1. However, antibiotic medicated shunts did not show a statistically significant association with reoperation rate (RR 0.99; 95% CI:0.81-1.20; p = 0.9) with no further need for evidence as per TSA.

Cavernous malformations of central nervous system in pediatric patients: our single-centered experience in 50 patients and review of literature.

PURPOSE: Cavernous malformations (CMs) are rare developmental cerebrovascular malformations of the central nervous system with a childhood prevalence of 0.3 to 0.53%. Our purpose was to assess the clinical features and microsurgical outcome in pediatric central nervous system (CNS) CMs. MATERIAL AND METHODS: We retrospectively enrolled all the CM patients admitted to our institute from 1 January 2001 to 31 December 2014. Data was analyzed for their clinical features and surgical outcome. RESULTS: A total of 50 patients with CMs (30 supratentorial, 14 infratentorial, and 6 spinal) with a mean age of 14 years (3-18 years, SD ±4.64) were enrolled into the study. Most of these patients (78%) were male. Size varied from 1.2 to 6 cm. Three patients had multiple CMs. Symptoms of CMs were site specific. Seizure was the most common symptom (63.3%) of CMs at supratentorial location followed by headache (46%) and neurodeficiency (26%), while all brainstem and spinal CMs presented with neurodeficiencies. History of clinically significant acute hemorrhage was present in 19.2% of supratentorial (ST) superficial CMs, 50% of ST deep CMs, 25% of cerebellar CMs, 44.4% of brainstem CMs, and 50% of spinal CMs. Forty-five CMs in 44 patients were surgically excised. Their follow-up ranged from 6 to 162 months (mean 47.2 months, SD ±53). All supratentorial CM patients showed improvement in their symptoms. Patients with preoperative seizure showed good seizure control with Engel scale I in 16 (94.1%) and Engel scale II in 1 (5.9%). In infratentorial (IT) and spinal CM patients, 92.3 and 66.7% had improvement in their neurodeficiencies, respectively. There was no mortality in our series. CONCLUSION: Microsurgical excision of CNS CM results in excellent neurological outcome in pediatric patients. Early intervention is necessary in spinal CMs for better outcome.

Decompressive craniectomy in traumatic brain injury: A single-center, multivariate analysis of 1,236 patients at a tertiary care hospital in India.

OBJECT: To evaluate the outcome of patients undergoing a decompressive craniectomy (DC) in traumatic brain injury (TBI) and the factors predicting outcome. MATERIALS AND METHODS: A total of 1,236 patients with TBI operated with a DC from January 2008 to December 2013 at a tertiary care hospital were included in the study. The data from the hospital computerized database was retrospectively analyzed and 324 (45%) patients were followed-up for a mean duration of 25.3 months (range 3-42 months) among the cohort of 720 alive patients. The institute's ethical committee clearance was obtained before the start of the study. RESULTS: There were 81% males with a median age [interquartile range (IQR)] of 32 (23-45) years. The mortality rate and median (IQR) Glasgow outcome score (GOS) at discharge in patients presenting with minor, moderate, and severe head injury were 18%, 5 (4-5); 28%, 4 (1-5); and 47.4%, 2 (1-4), respectively. An overall favorable outcome (GOS 4 and 5) at discharge was observed in 46.5% patients and in 39% patients who presented with severe TBI. Only 7.5% patients were in a persistent vegetative state (PVS), while 78% had an overall favorable outcome at the last follow-up of surviving patients (P < 0.001). On multivariate analysis, the factors predictive of a favorable GOS at discharge were: a younger age (odds ratio (OR) 1.03, confidence interval (CI) = 1.02-1.04; P < 0.001), no pupillary abnormalities at admission (OR 2.28, CI = 1.72-3.02; P < 0.001), absence of preoperative hypotension (OR 1.91, CI = 1.08-3.38; P = 0.02), an isolated TBI (OR 1.42, CI = 1.08-1.86; P = 0.01), absence of a preoperative infarct (OR 3.68, CI = 1.74-7.81; P = 0.001), presence of a minor head injury (OR 6.33, CI = 4.07-9.86; P < 0.001), performing a duraplasty (OR 1.86, CI = 1.20-2.87; P = 0.005) rather than a slit durotomy (OR 3.95, CI = 1.67-9.35; P = 0.002), and, avoidance of a contralateral DC (OR 3.58, CI = 1.90-6.73; P < 0.001). CONCLUSIONS: The severity of head injury, performing a duraplasty rather than a slit durotomy, avoidance of a contralateral DC, and the presence of preoperative hypotension, infarct, and/or pupillary asymmetry have the highest odds of predicting the short term GOS at the time of discharge, after a DC in patients with TBI. Although DC carries a high risk of mortality, the probability of the survivors having a favorable outcome is significantly more as compared to those who remain in a PVS.

Suprasellar tuberculoma.

Tuberculosis is among the most lethal infectious diseases. Although incidence of intracranial tuberculosis is low in developed countries, it is still rampant in the developing world. The most common location of intracranial tuberculomas in adults is the cerebral hemisphere, and in children, the posterior fossa. The suprasellar tuberculomas are extremely rare and pose a diagnostic challenge. We describe a patient with concomitant suprasellar and cerebellar tuberculoma.

Atlanto-occipital assimilation: embryological basis and its clinical significance.

Atlanto-occipital assimilation is an osseous embryological anomaly of the craniovertebral junction in which the atlas (C1) is fused to the occiput of skull. Embryologically, this assimilation may happen due to failure of the segmentation and separation of the caudal occipital and the cranial cervical sclerotome. The segmentation clock is maintained by NOTCH and WNT signalling pathways along with Hox genes and retinoic acid. This condition is likely to be a consequence of mutation in above mentioned genes. The knowledge of this assimilation may be crucial for the clinicians as it may lead to various neurovascular symptoms. The present case report involves the analysis of atlanto-occipital assimilation with its clinical significance and embryological basis.

Large pontine tubercular abscess treated surgically.

Tuberculosis of the central nervous system (CNS) is a life threatening condition with 50% mortality in advanced disease and serious neurological deficits in those who survive. Tuberculous abscess is a rare manifestation of CNS tuberculosis, brainstem involvement being even rarer. The management of these conditions poses a great challenge to the treating physician. We report a case of large tubercular abscess of pons which increased in size on anti-tubercular treatment, but showed excellent improvement following craniotomy and aspiration.

Tadpole Sign in Filum Terminale Paragangliomas.

Two normotensive male patients came with complaints of low back pain. Contrast-enhanced magnetic resonance imaging of the lumbosacral spine revealed an enhancing intradural extramedullary lesion (at the L4-L5 vertebral level in the first patient and at the L2-L3 vertebral level in the second patient). The tumor resembled the head and caudal blood vessels the tail of a tadpole, thereby giving the "tadpole sign." This sign is an important radiologic and histopathologic correlate, which is helpful in preoperative diagnosis of spinal paraganglioma.

Complete resolution of syrinx after circumferential adhesiolysis without deformity correction in a case of 6 year old neglected cervical facet dislocation.

Neglected traumatic cervical dislocation can be difficult to treat as such and more so if they are accompanied by an associated post traumatic syringomyelia (PTS). We present the case of a 55 year old gentleman who had a traumatic C6-C7 grade 2 listhesis which was neglected and presented 6 year later with 6 months history of neck pain, spastic quadriparesis and bowel bladder involvement. The patient was diagnosed with a PTS extending from C4 to D5. The possible aetiology and management of such cases has been discussed. The patient was successfully treated with decompression, adhesiolysis of arachnoid bands and syringotomy without the correction of deformity. The patient improved neurologically and had complete resolution of syrinx at final followup.

A Reversible Cause of Cutaneous Rash in a Patient With Alcohol Consumption.

The most common cutaneous manifestations of alcoholism include urticarial reaction, flushing, porphyria cutanea tarda, psoriasis, rosacea, seborrheic dermatitis, and pruritus. Here, we present a case of a young male with a history of alcohol abuse who presented with non-blanching, petechial, and perifollicular macular rash secondary to vitamin C deficiency in view of poor oral intake. The rash improved significantly with vitamin C supplementation. Although rare in developed countries, clinicians should keep vitamin C deficiency as a differential diagnosis for skin rash in alcohol consumers.

Is Asterion a Reliable Surgical Landmark for the Transverse and Sigmoid Sinus Junction in Indian Skulls?

Background: Asterion is the junction of lambdoid, parietomastoid, and occipitomastoid sutures. In traditional anatomy teaching, it is believed that asterion sits over the transverse-sigmoid sinus junction (TSSJ). It is a significant surgical landmark for the placement of a burr hole in the retrosigmoid approach. Objective: The purpose of this study was to evaluate the asterion's accuracy as a TSSJ-specific external surgical landmark in the Indian population. Materials and Methods: 16 human dried skulls were obtained from the Department of Anatomy, AIIMS, New Delhi. The point of TSSJ was taken between the two lips and just posterior to the entry of the superior petrosal sinus. Asterion internally was localized with the help of a geometrical divider. The x- horizontal/ anterior and y- vertically superior (+)/ inferior (-) distances were measured from asterion (internally) to the TSSJ by a digital vernier caliper. Results: The mean horizontal distance (x) of the left side asterion & TSSJ was 10.3±1.0mm whereas the vertical distance (y) ranged between +2 to -4.3 mm. The mean horizontal distance (x) of the right side asterion & TSSJ was 13.5±1.4mm whereas the vertical distance (y) ranged between +3 to -4.2 mm. Conclusion: Asterion is not a reliable landmark for TSSJ in Indian skulls. The TSSJ with respect to asterion was found on average 10mm and 13.5mm anterior on the left and right side respectively, and mostly inferior (average 4.2mm) in 75% of the skulls. The TSSJ was closer to the asterion on the left side in comparison with the right side. However, further studies with a larger sample size will be needed to evaluate the population-specific relation of asterion with the TSSJ.

Necrotizing Fasciitis In A Patient with Metastatic Clear Cell Ovarian Carcinoma Treated with Bevacizumab.

BACKGROUND Necrotizing fasciitis is a life-threatening infection of the deep soft tissues that leads to progressive destruction of the fascia and subcutaneous fat. It typically spreads along the muscle fascia planes because of the relatively poor blood supply. Muscle tissue is usually spared because of its better blood supply. The usual risk factors for necrotizing fasciitis include trauma, malnutrition, obesity, uncontrolled diabetes mellitus, alcoholism, cirrhosis, neutropenia, and recent surgery. CASE REPORT We present a case of a middle-aged female who presented with necrotizing fasciitis of the right gluteal region. Her medical history was significant for well-controlled diabetes mellitus (hemoglobin A1c: 6.6), and clear cell carcinoma of ovaries (stage IV). She was on active chemotherapy with bevacizumab, paclitaxel, and carboplatin. She underwent incision and debridement of right gluteal abscess with drainage of 200 ml of foul-smelling pus and was started on intravenous antibiotics. Her blood cultures were negative, but the cultures taken from the right gluteal abscess showed moderate growth of Escherichia coli. The antibiotics were de-escalated and the patient was discharged with outpatient follow-up. CONCLUSIONS Bevacizumab, a humanized monoclonal IgG antibody, is a novel treatment for metastatic ovarian cancer. It is associated with necrotizing fasciitis due to anti-angiogenic, pro-thrombotic, and poor wound healing properties. It should be stopped in the patients presenting with necrotizing fasciitis.