Versatility Of Square Flaps In Post-Burn Contractures Involving Upper Limb.

Post-burn contractures are a common problem and functionally limiting for upper limbs. Many different techniques have been described in the literature for their treatment. Z-plasty and release with SSG cover are the commonest procedures done for post-burn contractures. In this study we assess the use of the square flap technique in post-burn contractures of upper limb. Eleven patients with a total number of twelve upper limb contractures (mild to moderate) involving axilla, elbow and finger underwent release by standard square flap technique. All cases were followed up for at least 6 months and analyzed for range of motion and aesthetic outcome. Patient and surgeon satisfaction was recorded. All operated cases achieved a satisfactory range of movement post-operatively without any recurrence. The number of patients who were satisfied with the surgery were 7 out of 11, and 4 patients were somewhat satisfied with the results obtained. In contrast, the surgeons were satisfied in all cases. Square flap is shown to be an easy and reliable flap for mild to moderate contractures of the anterior or posterior axillary folds, elbow contractures and finger contractures with low recurrence rate.

Les rétractions séquellaires de brûlure sont fréquentes et engendrent des limitations fonctionnelles au membre supérieur. Beaucoup de techniques différentes ont été décrites dans la littérature pour leur traitement : plastie en Z, libération et couverture par greffe de peau, sont les techniques les plus couramment utilisées. Dans cette étude, nous évaluons l'usage du double lambeau rhomboïde ou lambeau carré de Hyakusoku dans les rétractions séquellaires de brûlure du membre supérieur. 11 patients représentant 12 rétractions au membre supérieur (minimes à modérées) intéressant la région axillaire, le coude, et les doigts ont bénéficié d'une libération de la rétraction par la technique du double lambeau rhomboïde ou lambeau carré de Hyakusoku. Tous les patients ont été suivis pendant au moins six mois post-opératoire. L'analyse porte à la fois sur les mobilités et le résultat esthétique. La satisfaction du patient et du chirurgien a été notée. Toutes les interventions ont permis une nette amélioration de la fonction, sans récidive. 7 patients sur 11 ont été satisfaits par le résultat du geste chirurgical et quatre patients ont été assez satisfaits. En revanche, les chirurgiens ont noté les résultats comme satisfaisants dans tous les cas. Le double lambeau rhomboïde ou lambeau carré de Hyakusoku semble donc être un lambeau simple et fiable dans le traitement des rétractions minimes à modérées des piliers axillaires antérieur ou postérieur, du coude ou des doigts avec un très faible taux de récidive.

Pathogenesis of intracranial aneurysm is mediated by proinflammatory cytokine TNFA and IFNG and through stochastic regulation of IL10 and TGFB1 by comorbid factors.

BACKGROUND: Intracranial aneurysm (IA) is often asymptomatic until the time of rupture resulting in subarachnoid hemorrhage (SAH).There is no precise biochemical or phenotype marker for diagnosis of aneurysm. Environmental risk factors that associate with IA can result in modifying the effect of inherited genetic factors and thereby increase the susceptibility to SAH. In addition subsequent to aneurismal rupture, the nature and quantum of inflammatory response might be critical for repair. Therefore, genetic liability to inflammatory response caused by polymorphisms in cytokine genes might be the common denominator for gene and environment in the development of aneurysm and complications associated with rupture. METHODS: Functionally relevant polymorphisms in the pro- and anti-inflammatory cytokine genes IL-1 complex (IL1A, IL1B, and IL1RN), TNFA, IFNG, IL3, IL6, IL12B, IL1RN, TGFB1, IL4, and IL10] were screened in radiologically confirmed 220 IA patients and 250 controls from genetically stratified Malayalam-speaking Dravidian ethnic population of south India. Subgroup analyses with genetic and environmental variables were also carried out. RESULTS: Pro-inflammatory cytokines TNFA rs361525, IFNG rs2069718, and anti-inflammatory cytokine IL10 rs1800871 and rs1800872 were found to be significantly associated with IA, independent of epidemiological factors. TGFB1 rs1800469 polymorphism was observed to be associated with IA through co-modifying factors such as hypertension and gender. Functional prediction of all the associated SNPs of TNFA, IL10, and TGFB1 indicates their potential role in transcriptional regulation. Meta-analysis further reiterates that IL1 gene cluster and IL6 were not associated with IA. CONCLUSIONS: The study suggests that chronic exposure to inflammatory response mediated by genetic variants in pro-inflammatory cytokines TNFA and IFNG could be a primary event, while stochastic regulation of IL10 and TGFB1 response mediated by comorbid factors such as hypertension may augment the pathogenesis of IA through vascular matrix degradation. The implication and interaction of these genetic variants under a specific environmental background will help us identify the resultant phenotypic variation in the pathogenesis of intracranial aneurysm. Identifying genetic risk factors for inflammation might also help in understanding and addressing the posttraumatic complications following the aneurismal rupture.

Association of Versican (VCAN) gene polymorphisms rs251124 and rs2287926 (G428D), with intracranial aneurysm.

Intracranial aneurysm (IA) accounts for 85% of Subarachnoid Hemorrhage (SAH) and is mainly caused due to the weakening of arterial wall. The structural integrity of the intracranial arteries is mainly influenced by the extracellular matrix (ECM) remodeling. The Proteoglycan Versican plays an important role in extracellular matrix assembly and plays a major role in the pathogenesis of IA. The linkage studies also indicated VCAN as a putative candidate gene for IA in the 5q22-31 region. Using a case-control study design, we tested the hypothesis whether the variants in VCAN gene, nonsynonymous variants in the coding region of Glycosaminoglycan α (GAG-α) and GAG-ß and two reported SNPs involved in splicing rs251124 and rs173686 can increase the risk of aSAH among South Indian patients, either independently, or by interacting with other risk factors of the disease. We selected 200 radiologically confirmed aneurysmal cases and 250 ethnically, age and sex matched controls from the Dravidian Malayalam speaking population of South India. The present study reiterated the earlier association of rs251124 with intracranial aneurysm (P = 0.0002) and also found a novel association with rs2287926 (G428D) in exon 7 coding for GAG-α with intracranial aneurysm (P = 0.0015). Interestingly, both these SNPs contributed to higher risk for aneurysm in males. In-silico analysis predicted this SNP to have the highest functional relevance in the gene which might have a potentially altered regulatory role in transcription and splicing. Using meta-analysis with available literature rs251124 was found to be the strongest intracranial aneurysm marker for global ethnicities. This study with a novel functional SNP rs2287926 (G428D) further substantiates the potential role of VCAN in the pathogenesis of IA.

Lack of association of lysyl oxidase (LOX) gene polymorphisms with intracranial aneurysm in a south Indian population.

Intracranial aneurysm (IA) accounts for 85 % of haemorrhagic stroke and is mainly caused due to weakening of arterial wall. Lysyl oxidase (LOX) is a cuproenzyme involved in cross linking structural proteins collagen and elastin, thus providing structural stability to artery. Using a case-control study design, we tested the hypothesis whether the variants in LOX gene flanking the two LD block, can increase risk of aSAH among South Indian patients, either independently, or by interacting with other risk factors of the disease. SNPs were genotyped by fluorescence-based competitive allele-specific PCR (KASPar) chemistry. We selected 200 radiologically confirmed aneurysmal cases and 235 ethnically and age and gender matched controls from the Dravidian Malayalam speaking population of South India. We observed marked interethnic differences in the genotype distribution of LOX variants when compared to Japanese and African populations. However, there was no significant association with any of the LOX variants with IA. This study also could not observe any significant role of LOX polymorphisms in influencing IA either directly or indirectly through its confounding factors such as hypertension and gender in South Indian population.

Risk factors for aneurysmal subarachnoid hemorrhage in an Indian population.

BACKGROUND: Aneurysmal subarachnoid hemorrhage (aSAH) has a mortality rate as high as 50%. The prevalence of intracranial aneurysms from various parts of India varies from 0.75 to 10.3%, with higher numbers of cases being diagnosed due to the increasing age of the population and improvements in imaging techniques. However, little is known about the attributable risk factors of aSAH in the Indian population. METHODS: Using a case-control study we estimated the risk of factors such as hypertension, cigarette smoking, alcohol consumption, diabetes mellitus and family history of aSAH in a South Indian population. The population-attributable risk (PAR) of smoking, hypertension and alcohol use was estimated for the South Indian as well as for the general Indian population. RESULTS: Our results showed that cigarette smoking (OR, 3.59; p < 0.001) and a history of hypertension (OR, 2.98; p < 0.001) were significant risk factors associated with aSAH. When patients were classified by gender, it was observed that being a smoker and having hypertension increased the risk for aSAH by nearly fourfold in men. Among women, hypertension and older age were significant risk factors. The PAR estimates indicated that smoking (OR, 3.59; 95% CI, 2.13-6.06) and hypertension (OR, 2.98; 95% CI, 1.73-5.12) are significant risk factors. CONCLUSIONS: Hypertension and smoking may be causal risk factors which might also modify the effect of genetic factors that could increase susceptibility to aSAH in the Indian population. Since these risk factors are amenable to effective modification, our findings will be useful for a gender-specific management of aSAH.

Pre-coronal, paramedian minicraniotomy: a minimal access approach for microsurgical, transcallosal, transforaminal removal of colloid cysts of the third ventricle.

OBJECTIVE: Microsurgical excision of colloid cysts of the third ventricle is accomplished along the transcallosal or the transfrontal routes. In the transcallosal approach, venous tributaries of the superior sagittal sinus can often act as an impediment to entry into the interhemispheric fissure for accessing the corpus callosum. We propose a paramedian minicraniotomy anterior to the coronal suture for removing colloid cysts via the transcallosal approach as veins are relatively rare in this area. METHODS: A triangular minicraniotomy was designed with each side measuring 3 cm based on the midline in the pre-coronal area of the frontal bone on the right side. Nineteen cases of symptomatic colloid cysts of the third ventricle whose diagnoses were proven by CT and/or MRI were subjected to microsurgery in the period from June 2004 to May 2007. Following the minicraniotomy the cysts were removed utilizing the transcallosal transforaminal route. RESULTS: Venous tributaries crossing the interhemispheric fissure were seen in 2 patients and these could be avoided to access the corpus callosum. Complete excision could be achieved in all cases. All patients had a good outcome although one patient had transient left lower limb weakness. The mean operating time was 163 minutes, while the mean duration of stay in the intensive care unit and hospitalization were 1.35 days and 3.73 days, respectively. CONCLUSION: The pre-coronal, paramedian minicraniotomy is safe and effective for the total excision of colloid cysts of the third ventricle. As a minimal access approach, it needs only a short duration of postoperative hospitalized care.

Role of endothelial nitric oxide synthase gene polymorphisms in predicting aneurysmal subarachnoid hemorrhage in South Indian patients.

Endothelial nitric oxide synthase (eNOS) gene polymorphisms have been implicated as predisposing genetic factors that can predict aneurysmal subarachnoid hemorrhage (aSAH), but with controversial results from different populations. Using a case-control study design, we tested the hypothesis whether variants in eNOS gene can increase risk of aSAH among South Indian patients, either independently, or by interacting with other risk factors of the disease. We enrolled 122 patients, along with 224 ethnically matched controls. We screened the intron-4 27-bp VNTR, the promoter T-786C and the exon-7 G894T SNPs in the eNOS gene. We found marked interethnic differences in the genotype distribution of eNOS variants when comparing the South Indian population with the reported frequencies from Caucasian and Japanese populations. Genotype distributions in control and patient populations were found to be in Hardy-Weinberg equilibrium. In patients, the allele, genotype and estimated haplotype frequencies did not differ significantly from the controls. Multiple logistic regression indicated hypertension and smoking as risk factors for the disease, however the risk alleles did not have any interaction with these risk factors. Although the eNOS polymorphisms were not found to be a likely risk factor for aSAH, the role of factors such as ethnicity, gender, smoking and hypertension should be evaluated cautiously to understand the genotype to phenotype conversion.

Cosmetic and radiological outcome following the use of synthetic hydroxyapatite porous-dense bilayer burr-hole buttons.

BACKGROUND: Cranial neurosurgical procedures utilising burr-holes lead to development of cosmetically unacceptable puckered scars on the scalp over burr-hole sites. Ceramics, especially Hydroxyapatite (HA) are good bone substitutes owing to their biocompatibility and osteoconduction i.e. ability to lay down bone over the implant by fibrovascular invasion and later bone formation. The Sree Chitra Tirunal Institute for Medical Sciences and Technology in India has pioneered research in this direction and has developed a unique porous-dense bilayer HA burr-hole button. This study evaluates the safety, cosmetic effect, as well as the radiological outcome following implantation of these bilayer HA buttons. METHOD: Sixty-five HA buttons were implanted in 22 patients who underwent cranial neurosurgical procedures at the Sree Chitra Tirunal Institute for Medical Sciences and Technology. We assessed the cosmetic outcome (absence of puckered scar over burr hole sites, absence of allergic reactions or infections associated with the implant) as well as the radiological outcome with X-rays at specified intervals and looked for interference in the postoperative neurological imaging due to the implants. RESULTS: There were no adverse events related to the HA buttons in the form of allergic reactions or infections. The implants persisted as radio-dense opacities on skull X-rays of recipients for up to two years. It did not lead to artefacts on postoperative CT or MR imaging of the brain. In particular, the HA buttons could be subtracted on Digital Subtraction Angiography and did not obstruct visualisation of the cerebral vasculature. CONCLUSION: The bi-layer porous-dense HA buttons are useful in preventing cosmetic defects over burr-hole sites on the scalp after cranial neurosurgical procedures. It does not interfere with current radiological imaging methods in the postoperative phase.

Anomalous origin of the callosomarginal artery from the A1 segment with an associated saccular aneurysm.

Although anatomic variations are well known in the A1 segment of the anterior cerebral artery (ACA), anomalous origin of a cortical artery from the A1 segment is extremely rare. The only reported cortical branch to arise from the A1 segment is the fronto-orbital artery. We report a case of anomalous origin of the callosomarginal artery (CMA) in association with a saccular aneurysm from the A1 segment of the left ACA in a 35-year-old man who presented with intracerebral hemorrhage. To our knowledge, this is the first report of anomalous origin of the CMA from the A1 segment.

Clinico-pathological study of cerebral aneurysms.

AIMS AND OBJECTIVES: A clinico-pathological study of cerebral aneurysms was undertaken to understand the histopathogical nature of the lesions and to ascertain possible etiological risk factors. MATERIAL AND METHODS: Of the 255 cases of cerebral aneurysms operated upon at our Institute during the two-year period between Jan 1999 to Dec 2000, a detailed study was conducted on 57 cases where the aneurysm sac could be excised and subjected to histopathological examination. Aneurysm sacs were fixed in 10% buffered formaldehyde and processed through graded alcohol. Paraffin-embedded sections were examined, using hematoxylin and eosin, Verhoeff van Gieson's and toluidine blue staining techniques. Histopathological observations were analyzed and correlated with clinical features. RESULTS: The ages of the patients ranged from 17-65 years and there were 33 males and 24 females. Twenty-six patients were chronic smokers and 19 patients had hypertension. There were 54 saccular and 3 fusiform aneurysms, predominantly involving the anterior circulation (52 cases) than posterior circulation (5 cases). In 35 cases, histopathological studies demonstrated mucoid deposits between hyperplastic cellular elements in the true and false aneurysm wall and/or parent artery or vasavasora. The changes were associated with dystrophic changes in the internal elastic lamina. CONCLUSION: Besides significant risk factors like smoking and hypertension, such mucoid vasculopathic changes may have predisposed vessels to structural weakness and aneurysm formation in our patients.

P.C. Sen Memorial best paper award on rural health practice: A study on visual acuity and vitamin A deficiency among primary school students in Naxalbari Village, Darjeeling district of West Bengal.

331 primary school students studying from Nursery classes to Class IV in 2 randomly selected schools in Naxalbari Village in Darjeeling district of West Bengal were tested for visual acuity (VA), Vitamin A deficiency (VAD) and Bitot's spot. 329 students could be tested for visual acuity whereas all 331 students were tested for VAD and Bitot's spot. The prevalence of abnormal Visual Acuity (VA) (VA < 6/9 in any eye) in this study group was 3.65% and it was highest in 7-8 years age group in both the sexes contributing to 75% of the total students having abnormal VA. All these children fell within 50th percentile of weight and height for their respective age and sex. Hindu & ST children accounted for 91.67% & 50% abnormal VA respectively; however, when presence of abnormal VA was compared with its absence between 2 sexes, Hindu and Muslim students and in different castes, no statistically significant differences were found (p > .05). Students of Class-I and Class-II contributed 25% and 50% respectively and together accounted for 75% of abnormal VA. Prevalence of VAD was 8.16%. Among sufferers of VAD Hindus (81.48%) and ST (51.85%) were the main contributors; the differences between presence and absence of VAD in 2 sexes, among 3 religious groups were not statistically significant (p > .05); however, differences among ST and NonSCST groups, and again SC, ST and Non-SCST groups were statistically significant (p < .05). Prevalence of Bitot's spot was 3.63%. Among the students having Bitot's spot, females (58.33%) outnumber the males (41.67%); but the difference between presence and absence of Bitot's spot in 2 sexes was not statistically significant (p > .05). 83.33% each of Hindus and STs had Bitot's spot. No SC and no Muslim student had this spot; the differences between presence and absence of Bitot's spot between Hindu and Christian students were statistically significant (p < .01); similarly when the findings were considered between ST and NonSCST students the difference was found to be statistically highly significant (p < .001).

Cerebellar hemisphere, an uncommon location for pleomorphic xanthoastrocytoma and lipidized glioblastoma multiformis.

Lipidized glioblastoma multiformis (LGB) and pleomorphic xanthoastrocytoma (PXA) are often supratentorial in location and occur in the second to fourth decade. This report presents two young patients, one having LGB and the other having PXA in the cerebellum. Histological differentiation between LGB and PXA is discussed.

Rhabdoid tumor of the thalamus.

Rhabdoid tumors of the central nervous system are uncommon tumors. About 188 cases have been reported in the literature so far. In this report, we describe a case of a rhabdoid tumor of the thalamus in a 35-year-old male patient. Light microscopic and immunohistochemical features are discussed and the relevant literature reviewed.

Liponeurocytoma of the cerebellum--a case report.

We report the characteristic neuropathological features of a rare case of cerebellar liponeurocytoma in a 62-year-old female. The tumor has a low proliferative potential and carries a favorable prognosis.

Carotid artery injury during transsphenoidal resection of pituitary tumor: anesthesia perspective.

The authors describe two patients who suffered carotid artery injury during transsphenoidal resection of a pituitary tumor. Anesthesiologists were involved in resuscitation after initial hemorrhage, in securing the airway, in initiating cerebral protection strategies, and in transporting these patients. Anesthesia was provided for resection of the tumors, removal of packs from the pituitary fossae, and diagnostic and therapeutic radiologic procedures. In each case hemostasis was achieved by packing the sella turcica, sphenoid sinus, and nostrils. Both patients were electively ventilated. In one patient, a pseudoaneurysm of the carotid artery was detected by angiography in the operating room. It was treated by trapping the internal carotid artery. The other patient developed a carotid-cavernous fistula, which was treated by balloon embolization. Both patients were discharged after dealing with these complications.

An uncommon case of neck fistula.

Congenital fistulae of the neck are branchial in origin and of these 2nd arch fistula is by far the most common, 3rd and 4th arch fistulae being very rare. Here, a case of fistula present since birth and extending from the neck, near the midline to the alveololingual sulcus, considered very rare, is presented. The patient was a 32-year-old male having sticky discharge through an opening in the upper part of the neck. Examination revealed an opening of approximately 1 mm diameter about 1 cm to the left of the midline just above the hyoid bone. A sinogram revealed a fistulous linear tract communicating with the oral cavity. Surgery was undertaken and the fistulous tract was excised.

False aneurysm of cavernous carotid artery and carotid cavernous fistula: complications following transsphenoidal surgery.

We present two cases of carotid injury during transsphenoidal surgery for pituitary adenoma. While in one of the cases it resulted in the formation of a false aneurysm of cavernous carotid artery, in the other patient, a carotid cavernous fistula (CCF) formed. The false aneurysm was managed by surgical trapping and the patient had an uneventful recovery. The CCF was initially managed with balloon embolization. The balloon got deflated and resulted in a false aneurysm with persistent CCF. This was occluded with Guglielmi Detachable Coils (GDC). The management options are discussed and relevant literature is reviewed. We emphasize the importance of an early cerebral angiography to know the status of the injured carotid artery and formation of false aneurysm / fistula.