Outcome of Surgical Treatment in Medically Refractory Epilepsy.

The aim of epilepsy surgery is not only to control seizures but also to curtail future adverse neurological sequelae and improve quality of life. Epilepsy surgery is a viable treatment option for selected cases of medically refractory epilepsy. A study was carried out with a series of 34 cases who underwent epilepsy surgery at Sree Chitra Tirunal Institute for Medical Science & Technology, Kerala, India during July, 2010 to December, 2010. Clinical features, operative procedures and early response to treatment were cha'racterized. Among 34 cases, main clinical manifestation was recurrent seizures. All cases were evaluated by Video Electro Encephalogram (EEG) & Magnetic Resonance Imaging (MRI) of brain with epilepsy protocol. Nearly 58% cases were diagnosed as mesial temporal sclerosis who were treated by anterior temporal lobectomy (ATL) with amygdalohippocampectomy (AH). Excision of epileptogenic foci was confirmed by preoperative Electro Cardiogram. Early response to surgery was good. However, a prolonged longitudinal follow up is essential for accurate assessment of seizure outcome.

Correlation between intracerebral hemorrhage score and surgical outcome of spontaneous intracerebral hemorrhage.

Spontaneous intracerebral hemorrhage (ICH) comprises 10-15% of all strokes and has a higher risk of morbidity and mortality (40-45%). A simple and widely valid clinical grading scale, the Intracerebral Hemorrhage Score (ICH score) was developed to predict to outcome of spontaneous ICH. The aim of the present study was to assess the relation between the ICH score and the surgical outcome of ICH by Glasgow Outcome Scale (GOS) at the 30th post ictus day in our perspective. This prospective study was done during the period of April 2009 to October 2010 in Department of Neurosurgery, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka. Forty three cases were enrolled by set inclusion and exclusion criteria. Intracerebral Hemorrhage Score was calculated during admission and the surgical outcome of ICH was determined by GOS by face to face or telephone interview using structured questionnaire on their 30th post ictus day. Correlation between the ICH score and the surgical outcome of ICH was done by Pearson's correlation coefficient test. Value of r was found to be -0.635 which was statistically highly significant (p = .001) and the relation was found to be negative. Higher ICH score had unfavorable outcome As correlation between the ICH score and the surgical outcome of ICH was found statistically highly significant, it can be used widely as a grading scale in preoperative counseling. The use of ICH score could improve standardization of clinical treatment protocols and clinical research studies in ICH.

A primary spinal hydatid cyst.

Hydatid disease occurs in humans as a result of faeco-oral contamination. Spinal hydatid cyst is a rare entity and a serious form of hydatid disease affecting less than 1% of the total cases of hydatid disease. Neural compression is common in vertebral hydatidosis where prognosis is always considered as very poor. Difficulty in management due to recurrence of this rare entity makes it a challenging disease to eradicate entirely. Efficacy of use of anthelminthic even after complete surgical removal is yet to be established. We are reporting diagnosis and management of a case of primary extradural and paraspinal hydatid cyst (HC) in an otherwise healthy patient who did not show any other evidence of systemic hydatid disease. The diagnosis was recognized preoperatively by magnetic resonance imaging (MRI) and confirmed postoperatively by histopathology. Surgical removal of the cysts/lesions was followed by anti-helminthic medication and recovery was satisfactory until the patient had recurrence after one year. The patient underwent surgery for the second time and was given anti-helminthic again for a longer period and was recurrence free for the next one year.

Primary disseminated MDR-TB in a Bangladeshi man: a silent and emerging clinical problem for clinicians.

A 26 years old Bangladeshi man experienced sudden gross haematuria for 10 days when he was working in Italy in June'07 that was resolved spontaneously. Six months' later he again developed haematuria and was admitted into an Italian hospital for its evaluation and management. In the mean time, he developed low grade fever, cough, back pain, spinal angulations, walking difficulty. His X-ray chest postero-anterior view revealed cavitary lesions in upper zones of both lung fields. Intravenous Urography (IVU) was done which revealed hydronephrosis and hydroureter of left kidney. Magnetic Resonance Imaging (MRI) of dorso-lumber spine revealed collapse of D10-12 and L4-5 vertebral bodies with perivertebral and epidural abscess. Sputum and urine smear for Acid-Fast-Bacilli (AFB) demonstrated the organisms on Z-N stain and AFB culture and sensitivity demonstrated that it was resistant to isoniazide, Rifampicin and streptomycin and diagnosed as primary disseminated multi-drug Resistant tuberculosis (MDR-TB). Second-line drugs were started in Italy on 15th January'08 and were continued thereafter in National Institute of Diseases of the Chest and Hospital (NIDCH). A ureteric stent which was given in Italy to get relief of hydro-ureter was removed in Dhaka. A neurosurgery (costo-transversectomy with decompression of spine) was done in Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka and patient get relief of back pain paresthesia. Lastly, his sputum and urine AFB smear and AFB culture became negative. So, primary disseminated MDR-TB with renal, spinal and pulmonary involvement was diagnosed in this Bangladeshi man who had a sputum AFB culture and sensitivity during his initial diagnostic work-up in Italy. It's an alarming case that demonstrated necessity of sputum AFB culture and sensitivity during initial diagnostic work-up.

Variation between CT scan findings and histological diagnosis of intracranial glioma.

A total of 45 cases were studied to elucidate the variation between CT scan findings and histological diagnosis of intracranial glioma. They were operated and histopathological examination of all cases was studied. The mean age of the patients were 35+/-2.37 years and ranged from 01 to 65 years. The highest incidence of glioma was found in age group between 40-50 years. The incidence of glioma was more in male 36(80%) in comparison to female 9(20%). The main presenting complaints were headache in 42(93.3%), vomiting in 34(75%), limb weakness in 28(62.2%) and blurring of vision were in 26(57.8%) patients. Other symptoms were convulsion in 29(64.4%) patients and altered consciousness 24(53.3%) patients. By CT scan, diagnosis was made as informed gliomas in all cases. Histopathological examination showed 41(91.1%) cases were gliomas and 3(6.7%) were meningiomas and 1(2.2%) was brain abscess. So there were little variations between CT scan findings and histopathological diagnosis.

Primary Non-Hodgkin Lymphoma of Sphenoid Sinus Involving Cavernus Sinus and Clivus with Isolated 3rd Nerve Palsy.

Lymphomas are group of malignant neoplasm having origins from lymphoreticular cells. B cell Non Hodgkin Lymphoma (BNHL) of sphenoid sinus as primary site for lymphomas are very rare and whenever involves comes usually with ocular manifestations. The proximity of the lesion to optic nerve and cavernous sinus present a high risk of developing unilateral ophthalmoplegia or even blindness. The vast majority of cases of localized sphenoid sinus lymphomas are usually curable to surgery, chemotherapy alone or combination of both, sometimes radiotherapy. Here we report a case of 58 years old male attended at Bangabandhu Sheikh Mujib Medical University (BSMMU) on 9th February 2017 at 9:00 AM having headache and gradually developing ptosis in left eye over 15 days. MRI of brain revealed homogeneously enhancing lesion occupying sphenoid sinus, clivus extending towards left cavernous sinus. Gross total resection of tumor was achieved by endoscopic endonasal approach. Histopathology revealed non-Hodgkin lymphoma and immunohistochemically it was positive for CD 20, CD 45, CD 79 and BCL 2, strongly compatible with diffuse large B cell lymphoma. Treatment with R-CHOP regimen following surgery resulted in initiation of improvement of the condition of the patient. Primary B cell Non-Hodgkin Lymphoma (PBNHL) of the sphenoid sinus is a rare entity which can be perplexing and misleading for a surgeon until the histopathological proof is in hand. Early diagnosis with strong suspicion of sphenoid lymphoma in mind during workouts and timely management, close monitoring and follow ups have high potential for cure and longer disease-free survival of the BNHL patients.

Spontaneous peritumoral haemorrhage associated with sinus confluence meningioma: case report.

BACKGROUND: Torcular or sinus confluence meningioma is rare and surgically formidable. This reported sinus confluence meningioma was associated with peritumoral intracerebral hemorrhage. The surgical strategy and the mechanism of peritumoral hemorrhage are discussed. CASE DESCRIPTION: A 42-year-old woman presented with a history of headache, vomiting, and cerebellar dysfunction for 2 months. Plain computed tomography (CT) scan and magnetic resonance imaging (MRI) demonstrated a high-density mass in the torcular region involving both lateral sinuses. MR angiography demonstrated complete occlusion of the left lateral sinus and straight sinus and stenosis of the right lateral sinus. Two years after her first operation she experienced sudden headache and left upper quadrant hemianopsia. Plain CT scan and MRI showed a hyperintense tumor in the torcular region with an intracerebral hematoma in the right occipital lobe. An angiogram demonstrated occlusion of the caudal part of the superior sagittal sinus, bilateral transverse sinuses, and straight sinus. Gross total removal of the tumor was done along with the left lateral sinus through a suboccipital and a supratentorial occipital craniotomy in the first operation. The patient underwent total resection of the tumor at second operation through a bilateral occipital and suboccipital craniotomy along with resection of the dura including the confluence, the caudal part of the superior sagittal sinus, the right lateral sinus, and the straight sinus. The postoperative course was uneventful and postoperative MRI showed total removal of the tumor. CONCLUSION: Sinus confluence meningioma may present with peritumoral hemorrhage. Radical removal may be possible when the sinus confluence is completely occluded and there is good collateral drainage.

Surgical approaches and strategies for skull base chordomas.

OBJECT: The management of chordomas involving the skull base continues to present a number of treatment-related problems. Recently, both radical resection and charged-particle irradiation or stereotactic radiosurgery have reportedly been found effective for tumor control and for promoting a better quality of life in patients. In this article the authors analyzed the outcomes in 17 patients with skull base chordomas who were surgically treated at Kobe University Hospital between 1972 and 2000. METHODS: Preoperative radiological examinations included magnetic resonance imaging, computerized tomography, angiography, and balloon occlusion test of the internal carotid artery. Among the various surgical approaches used to remove the tumor were the frontoorbitozygomatic, transmaxillary, transcondylar, transsphenoidal, and the transbasal. Total removal was achieved in two (12%), near-total removal in three (18%), subtotal removal in nine (52%), and partial removal in three patients (18%). Since 1990, chordomas have been radically resected via various skull base approaches; the combined total or near-total removal rate has been 80% in this period. Radical removal of the tumors has not led to an increased risk. At the final follow-up review (mean 59.5 month), 75% of the patients were still alive, and 25% had died of chordoma recurrence. The overall recurrence-free survival rate was 82% at 3 years and 51% at 5 years. The 5-year recurrence-free survival rate in the five patients who underwent the operation during the past decade was 77% (mean follow up of 5.2 years). In two patients with recurrent tumors who underwent radiosurgery, no evidence of tumor regrowth was demonstrated at 3 years posttreatment. CONCLUSIONS: The authors suggest that for the treatment of skull base chordomas radical resection is a key factor for longer survival and improved quality of life. Patients with sufficiently small tumors, which show a favorable configuration and location, can be suitable candidates for stereotactic radiosurgery.

A clinical review of large cerebello pontile angle tumors.

The study was designed as retro-prospective and the study period was 3.5 years. A total of 66 (42 prospective and 24 retrospective) consecutive patients were included in the study. The commonest tumor in CPA is the Schwannoma (76%) followed by Meningioma (13.3%) and Epidermoid (4.44%). Unusual forms are Ependymoma and Hemangiopericytoma. Amongst the troublesome clinical features headache, hearing loss, vertigo and imbalance, vomiting and tinnitus were more important besides visual failure and features of lower cranial nerve involvement. The objective of the study is to "Review the Large Cerebello Pontile Angle tumors clinically". In this study 66 large CPA tumors were included and analyzed. Analysis of variance (ANOVA) was implied for the test of significance. On the whole, n=66 Schwannoma represents 76.70% and Meningioma 15.38%. Of these there are 45 cases with histological verification. The most common presenting (average duration is 1.3 years) symptoms were Headache (94.54%) and Hearing loss of varying grade (85.45%). Vertigo or imbalance was present in 67.27% cases. Vomiting was found in 54.54% of the times and difficulties in deglutition or voice change were complained of in 29.09% cases. Tinnitus was found only in 27.27% cases and it was the complaint mostly in lower diameter tumors. By maximum diameter, there were 24 cases measuring 3-4 cm, 15 more than 4 cm and only one case <3 cm sized tumors. Volume-wise tumors with volume <10 cc were 5 cases, 10-20 cc were 10, 20-30 cc were 13, 30-40 cc were 6 and >40 cc were 6. Similarly tumor volume and posterior fossa volume ratio was as follows: <10% were 6 cases, 10-20% were 15 cases, 20-30% were 7 cases and >30% were 6 cases. Amongst the schwannomas, the consistency of the tumor has been shown to be important factor for LCN involvement. The softer variety involved LCN more often than the harder (p<0.05). The involvement of the different groups of lower cranial nerve ranged from 7% to 92%.