Resolution of Long-Standing Diabetes Mellitus Two Years After Surgery for Growth Hormone Producing Pituitary Tumor.

Excess serum growth hormone (GH) induces insulin resistance leading to reduced uptake of glucose in peripheral tissues, gluconeogenesis in the liver and lipolysis and finally an increase in the blood glucose levels. We report a case where a 54-year-old woman presented with uncontrolled blood glucose levels since 5 years. On examination, she had signs and symptoms consistent with acromegaly including recurrent headaches, sleep apnea, soft tissue swelling, enlargements of the feet, hands, ears and lips, mandibular overgrowth, forehead protrusio and teeth spacing. She was on oral hypoglycemic agents (OHAs) for 12 years before she visited our hospital, but the blood glucose levels have been uncontrolled for the past 5 years with recurrent hyperglycaemic and occasional hypoglycaemic events. She underwent pituitary surgery for GH producing tumor and 2 years post surgery, we had to stop all the medications for the diabetes mellitus. This indicates that even long-standing diabetes mellitus can resolve in some patients with acromegaly.

Unusual Complication of Paraplegia Following Intracranial Aneurysm Clipping in a Patient with Undiagnosed Coarctation of Aorta.

We report a case of subarachnoid hemorrhage in a 38-year-old male, diagnosed to have the right middle cerebral artery aneurysm on computed tomography (CT) cerebral angiogram. He was a known hypertensive for 17 years and was on irregular treatment. Craniotomy and clipping of the aneurysm were done. Postoperatively, the patient had high blood pressure of 200/120 mmHg. Treatment of hypertension in the postoperative period resulted in paraplegia. CT angiogram of aorta revealed coarctation-postductal type. He underwent balloon dilatation for the coarctation of aorta followed by coarctopalsty and stenting with the improvement in motor power in both lower limbs.

Aneurysm of azygos anterior cerebral artery: A report of two cases.

Aneurysms of azygos anterior cerebral artery (ACA) are rare with very few cases reported in medical literature. We report here two cases of aneurysm of azygos ACA among 105 patients with subarachnoid hemorrhage. The two aneurysms were successfully clipped by using the bifrontal basal interhemispheric approach.

Intracranial Pial Arteriovenous Fistulae: Diagnosis and Treatment Techniques in Pediatric Patients with Review of Literature.

Pial arteriovenous fistulae (AVF) are rare vascular lesions comprising single or multiple arterial feeders draining directly into the venous channel without intervening tangle of blood vessels as in brain AV malformations. In our present paper, we describe three cases of pial AVF in the pediatric age group with different presentations treated successfully with endovascular and surgical methods. Two patients underwent treatment for pial AVF by the endovascular technique and one by surgical clipping. The treatments were successful with good clinical outcome. We did not encounter any peri-procedural complications in any of the cases. Pial AVF is a rare entity and high degree of suspicion and adequate clinical and imaging knowledge is required to make the diagnosis. Exclusion of the fistula from the cerebral circulation should be done at the earliest to prevent devastating complications that result during the natural course of the disease.

Primary intracranial Parachordoma: An unusual tumor in brain.

BACKGROUND: Parachordomas are rare soft tissue tumors commonly occurring in limbs, chest, Abdomen, and back. The World Health Organization (WHO) classification includes parachordomas in the same group as mixed tumors and myoepitheliomas. Exact histogenesis of this tumor is unclear. CASE DESCRIPTION: A 52-year-old male presented with headache and blurring of vision since one month. Preoperative computed tomography (CT) scan of brain revealed left parieto-occipital tumor extending up to the trigone. Total excision of the tumor was done. Histopathologically, the tumor was composed of relatively uniform cells with eosinophilic cytoplasm in a myxoid stroma and with cartilaginous and osseous metaplasia. The tumoral cells were immunoreactive for cytokeratin, epithelial membrane antigen (EMA), S-100, and vimentin. The constellation of findings revealed the tumor to be parachordoma. Magnetic resonance imaging (MRI) brain during follow-up at one year showed no recurrent tumor. No adjuvant therapy was given to this patient. CONCLUSION: This is the first reported case of primary intracranial parachordoma. It is difficult to diagnose the lesion preoperatively by imaging alone. Long-term follow-up is necessary in view of few reports in literature of recurrence and metastasis, of parachordomas in other anatomical locations.

Emergency Neuroendoscopic Management of Third Ventricular Neurocysticercosis Cyst Presented with Bruns Syndrome : Report of Two Cases and Review of Literature

Neurocysticercosis is the commonest parasitic disease of the human central nervous system. The incidence of intra ventricular form of neurocysticercosis (NCC) is less common accounting 10-20% that of total central nerve system cysticercosis. Intra ventricular NCC is complicated due, to its high incidence of acute hydrocephalus caused by ball valve mechanism. The only reliable tool for diagnosis of NCC is by neuroimaging with CT or MRI. MRI preferred over CT because of its high specificity and sensitivity. In emergency situations like acute hydrocephalus one can proceed with emergency endoscopic surgery. Through the endoscopic view, intra ventricular NCC (IVNCC) has distinguished morphological features like the full moon sign. This feature not only helps in identification of IVNCC, but also guides in further endoscopic treatment strategy. Authors report two cases of 3rd ventricular NCC with acute hydrocephalus managed with emergency endoscopy. Authors have discussed the clinical features, intra operative endoscopic findings and role of endoscopy in emergency surgery for NCC with acute hydrocephalus.

A rare case of an extra-axial cavernous angioma in the cerebellopontine angle.

Intracranial extra-axial cavernous angiomas are rare lesions. We report a rare case of extra-axial cavernous angioma in the cerebellopontine angle (CPA) in a 50-year-old male, who presented with lower cranial nerve palsy and gait ataxia. Computed tomography (CT) scan of the brain showed a hyperdense lesion in the left cerebellopontine angle. The lesion was totally excised by the retrosigmoid approach and a pathological examination confirmed the lesion to be a cavernous angioma. Following surgery, the lower cranial nerve palsy recovered significantly.

Intracranial metastasis from primary spinal primitive neuroectodermal tumor.

Primary spinal primitive neuroectodermal tumors (PNET) are rare tumors, with only 94 cases reported till date. Metastasis to brain from a spinal PNET is even rarer. In the present report, we evaluate the pathology and treatment of solitary intracranial metastasis from spinal PNET in a 22-year-old female who presented with headache and left hemiparesis and was diagnosed to have right parietal parasagittal tumor. She has been previously diagnosed to have cervicothoracic primary spinal PNET, and was treated by surgery, radiotherapy, and chemotherapy seven years back. The intracranial tumor has been removed and pathological examination confirmed as PNET. She received radiotherapy and chemotherapy with ifosfamide and etoposide, following surgery for the right parietal PNET. At 20 months follow-up, patient is stable and has no recurrence of the disease. Critical review of reported cases of primary spinal PNET metastsising to brain was done.

Spinal epidural angiolipoma: A rare cause of spinal cord compression.

Spinal epidural angiolipomas are rare, benign tumors composed of mature lipocytes admixed with abnormal blood vessels. Only 128 cases of spinal epidural angiolipomas have been reported in literature till now. Spinal angiolipomas are predominantly located in the mid-thoracic region. We report a case of dorsal epidural angiolipoma in a 56-year-old male who presented with paraparesis and was diagnosed to have D4-5 epidural angiolipoma. Total surgical excision of the epidural angiolipoma was done and his paraparesis gradually improved.

Surgical excision of hypothalamic hamartoma in a twenty months old boy with precocious puberty.

A twenty months old boy presented to our department with true precocious puberty due to hypothalamic hamartoma. Total surgical excision of pedunculated hypothalamic hamartoma was done successfully by the pterional trans-sylvian approach as he could not afford medical management. Patient had uneventful post-operative course with normalization of serum testosterone levels and regression of secondary sexual characters.

Microvascular decompression treatment for trigeminal neuralgia.

PURPOSE: The purpose of the study was to evaluate the effectiveness of microvascular decompression treatment prospectively in 40 patients with trigeminal neuralgia who were resistant to medical treatments and underwent microvascular decompression surgery (MVDS) between the years 2008 and 2010. METHODS: The patients' data were collected as per norms suggested by Zakrzewska and Lopez and followed up using annual trigeminal neuralgia survey given by Zakrzewska et al, through direct interview during follow-up visits. Patients were operated on in supine position with lateral suboccipital surgical approach. RESULTS: Forty patients with a mean age of 48 (SD, 13) years underwent surgery. The etiological factors were estimated as idiopathic or vascular compression in 39 patients and epidermoid tumor in 1. During the postoperative period of 8 to 46 months, 37 (92.5%) of the patients were pain-free without any further medical treatment. CONCLUSIONS: Our result supports the notion that MVDS is the treatment of choice for patients with trigeminal neuralgia. Pure MVDS can offer long-term cure rate of more than 98% of success for neuralgia in the presence of clear-cut and marked vascular compression at surgery.

Poor-grade subarachnoid hemorrhage: is surgical clipping worthwhile?

BACKGROUND: Management of patients with poor-grade aneurysmal subarachnoid hemorrhage (SAH) is difficult and the protocols followed differ from center to center. MATERIAL AND METHODS: In this report, we present our experience with aneurysmal clipping in patients with poor-grade SAH. Patients with poor Hunt and Hess (H and H) grade (Grade IV and Grade V) were offered surgery after stabilization of their hemodynamic and metabolic parameters. The status was recorded as favorable (good recovery, mild to moderate disability but independent), unfavorable (severe disability, vegetative) and dead. RESULTS: Out of a total of 1196 patients who underwent aneurysmal clipping, 165(13.8%) were in poor grade. Of the 165 patients, 99 (60%) were in H and H Grade IV and 66 (40%) were in Grade V. More than half of the patients (58%) were operated within 24 h of admission. There was an overall mortality of 50.9%. In the long term, of the survivors who were followed up, about 72% achieved a favorable outcome. CONCLUSIONS: With an aggressive approach aimed at early clipping, the chances of rebleed are reduced and vasospasm can be managed more aggressively. This protocol resulted in survival in a significant proportion of patients who would have otherwise died. In the long-term follow-up, the surviving patients showed significant improvement from the status at discharge.

Thoracoscopic thymectomy for juvenile myasthenia gravis.

Thoracoscopic thymectomy is feasible in adolescents with myasthenia gravis. It allows complete resection of the gland with less morbidity, shorter ICU and hospital stay and far superior cosmetic result as compared to trans-sternal thymectomy. Our experience with this procedure in 9 adolescents with myasthenia gravis is presented along with review of the relevant literature.