Medulloblastoma with Subcutaneous Spread: A Rare Entity.

Medulloblastoma is the most common malignant pediatric brain tumor. Histological subclassification and adjuvant therapy have improved prognostication and outcome. Extraneural metastasis remains a poor prognostic factor and subcutaneous seeding is rarely encountered and reported in the pediatric population. We report a 3-year-old child who rapidly presented with subcutaneous seeding a month following gross total resection of his tumor.

Spontaneous Intracerebral Hemorrhage in the Young: An Institutional Registry Analysis.

Background: Spontaneous intracerebral hemorrhage (SICH) accounts for about 10-15% of all strokes. Generally, it is a disease of the elderly; worldwide, the incidence of SICH in the young is showing an increasing trend, especially in India and the Asian continent. An attempt is also made to analyze the presence of factors, which may predict the risk of SICH among young hypertensives. Methods: A six-year retrospective review of patients aged below 50 years who presented with SICH was included in the study. Patients with bleeds secondary to an identifiable cause such as tumor, trauma, vascular malformations, and coagulopathy-induced bleeds were excluded from the study. The outcome was measured at 90 days using the modified ranking scale, and predictors of outcome (good outcome modified ranking score (mRS): 0-3; poor outcome mRS: 4-6) were analyzed. Results: SICH in the young accounted for 28.4% of all intracerebral hemorrhage (ICH) patients admitted during the study period (344/1210). The mean age of our male-dominant (78.5%) cohort was 42.9 ± 6.24 years, and the median Glasgow coma score (GCS) on presentation was 11 (IQR: 8-14). A prior history of hypertension (HTN) was obtained in 51.2% (176), and left ventricular hypertrophy (LVH) was documented in 237 (68.9%) patients. The basal ganglia was the most common location of the bleed (62.2%). At 90 days, 200 patients (58.1%) had good outcome and 144 (41.9%) had poor outcome with an overall mortality of 75 (21.8%). Independent predictors of poor outcome were poor GCS, larger volume, and high serum creatinine values. Conclusion: The incidence of SICH among the young accounts for nearly 30% of admitted ICH. Poor outcome and mortality are high with HTN being the single most important modifiable risk factor in the cohort.

Surgical treatment of epilepsy - Initial experience from a comprehensive epilepsy program in coastal South India.

Objectives: The objectives of this study were to share our initial experience with epilepsy surgery and provide an overview on the surgical treatments of epilepsies. Materials and Methods: This was a retrospective analysis of the demographics and clinical and investigative features of patients who underwent epilepsy surgery between January 2016 and August 2021. Postoperative seizure outcome was categorized according to modified Engel's classification, and the minimum period of follow-up was 1 year. Results: The study group included 30 patients with an age ranging from 6 years to 45 years (mean: 22.28 years, median: 20 years) and a male: female ratio of 20:10. The epilepsy duration before surgery ranged from 3 years to 32 years (median: 7 years). Majority of our patients underwent resective surgeries (28/30 = 93.3%), and disconnection procedures were done in two patients. This included one functional hemispherotomy and one posterior quadrantic disconnection. Temporal lobe resective surgery was the most common procedure (16/30 = 53.3%), followed by eight frontal lobe and two parietal lobe surgeries. Among resective surgeries, majority were lesional surgeries and the pathologies included mesial temporal sclerosis (4), dysembryoplastic neuroepithelial tumor (8), ganglioglioma (6), cavernoma (4), focal cortical dysplasia (2), gliosis (1), and one case of hypothalamic hamartoma. Intraoperative electrocorticography was used in all cases for optimizing surgical resection/disconnection. Nearly two-thirds of our patients (66.6%) had an Engel's Class I outcome, five patients had Engel's Class II outcome, three patients had Class III outcome, and one patient did not have any worthwhile improvement. Temporal lobe surgery patients had a better seizure outcome compared to extratemporal surgeries (84% vs. 74%). Overall, complications were minimal and short lasting, and comprised meningitis in three patients (5.6%) and transient worsening of hemiparesis following hemispherotomy in two patients. There was no mortality or long-lasting major morbidity in our patients. Conclusion: In carefully selected patients with drug-resistant epilepsy, surgery offers an excellent chance of becoming seizure-free with significant improvement in overall quality of life. Majority of the common epilepsy surgery procedures can be performed through a multidisciplinary approach even in centers with limited resources.

Extraventricular Neurocytoma of the Posterior Fossa: A Case Report Written by ChatGPT.

ChatGPT (Chat Generative Pre-trained Transformer) is the latest artificial intelligence (AI) tool that has taken the internet by storm. A large language model-based AI tool, ChatGPT is used to generate natural prose-like answers learning from a large database of text. A lot is being written and spoken about the future of academic writing using this tool.We attempt to generate a short case report of a brain tumour labelled extraventriuclar neurocytoma (EVN) which is a rare tumour of the central nervous system. When posed with a set of questions on this uncommon topic, ChatGPT did well with relevant but not very specific answers. Validation of the information is an issue like with most machine learning solutions. This case report is an attempt to summarise EVN and its management. Q: Summarise extraventricular neurocytoma. ChatGPT: EVN is a rare and benign tumor that typically occurs in the brain. It often causes no symptoms, but as it grows, it can cause headaches, seizures, and changes in vision or balance. Surgery is usually curative, but there is a lack of studies to know the best treatment options. The prognosis is generally good with high rates of long-term survival and low rates of recurrence. Text italicised in the article is generated by ChatGPT.

Mini anterior interhemispheric approach for A3 segment distal anterior cerebral artery aneurysms.

INTRODUCTION: Aneurysms of the A3 segment of the distal anterior cerebral artery (DACA), in relation to the genu of the corpus callosum, are specific sub-group which pose unique surgical challenges due to their discrete anatomical location. We describe a mini-anterior interhemispheric approach which can be safely utilised to clip these aneurysms rather than the traditional bifrontal approach. METHODS: Retrospective analysis of the clinical and radiological data of ruptured DACA-A3 aneurysms operated between 2014 and 2021 at our institute. A curvilinear scalp incision within the hairline followed by raising small, unilateral, free frontal bone flap, avoiding the opening of frontal sinus. Superior sagittal sinus is displaced medially, inter-hemispheric dissection carried out with posterior trajectory and small callosotomy is performed. DACA is skeletonised, proximal control is established, and the A3 aneurysm is dissected and clipped. RESULT: Our cohort of 18 patients had a definite female preponderance (F:M::2:1) with mean age of 55.6 years. On admission three patients were categorized as WFNS Grade I, thirteen in Grade II, and two in Grade III for subarachnoid haemorrhage. All the patients had evidence of blood in the interhemispheric fissure; intraparenchymal haemorrhage was seen in seven, with intraventricular haemorrhage in six patients. Within the A3 segment six aneurysms were infragenu (inferior), eight were at the genu (anterior) and four were supragenu (superior). Two (11.1%) elderly patients succumbed post-surgery following ischemic infarcts and associated complications. At the time of follow-up at 3 months of the remaining sixteen (72.2%) patients, thirteen had a good outcome (mRS 0-3) and three (16.7%) had a poor outcome (mRS > 3). CONCLUSION: The mini anterior interhemispheric is an effective minimally invasive alternative for A3 segments aneurysms and helps to avoid the complications of the conventional bifrontal interhemispheric approach.

Pheochromocytoma with an unusual presentation.

Pheochromocytoma, is a rare neuroendocrine tumor, which usually presents as hypertension. We report a young male patient, who presented with intracerebral hemorrhage and intractable hypertension. On further evaluation, for uncontrolled secondary hypertension, he was diagnosed to have right adrenal pheochromocytoma. After hemodynamic stabilization, laparoscopic adrenelectomy was performed. Pheochromocytoma crisis presenting as intracerebral hemorrhage and cardiomyopathy is an uncommon phenomena. Even though it is a crisis, it is not a surgical emergency. Proper preoperative hemodynamic stabilization is essential before surgery is performed. An experienced anesthetist, to manage intraoperative fallacies, is warranted. Postoperatively, they must be on lifelong follow-up to watch for recurrence.

Fragment reattachment after complicated crown-root fractures of anterior teeth: A systematic review.

BACKGROUND/AIM: Fragment reattachment is a procedure that can immediately restore form and function in crown-root fracture cases and is considered a minimally invasive and cost-effective treatment option. The aim of this systematic review was to analyze the methods used and the outcome of fragment reattachment for complicated crown-root fractures of anterior teeth. MATERIALS AND METHODS: Five electronic databases (PubMed, Web of Science, Embase, Scopus, and Google Scholar) were searched for English language articles regarding fragment reattachment after complicated crown-root fractures of anterior teeth. RESULTS: Twelve case reports and two case series were selected for this review after applying the inclusion and exclusion criteria. In eleven articles, the fracture line was exposed prior to reattachment. Root canal treatment was performed in all cases except one, where conservative pulp treatment was done prior to reattachment. A post was used as part of the restoration in 85% of the cases. Additional fragment preparation was done in 42% of the cases in the form of beveling and groove formation. Adhesive strategies used to reattach the coronal fragments were total-etch, self-etch, or self-cure adhesive. Intermediate materials used for reattachment were resin cement, glass-ionomer cement, composite and self-adhesive cement. Treatment outcomes were favorable in all the included articles and the follow-up period ranged from three months to seven years. CONCLUSION: Fragment reattachment after complicated crown-root fractures of anterior teeth can be considered as a viable treatment option if the clinical conditions are favorable.