Perforator-Based Propeller Flap with Additional Venous Pedicle for Lower Limb Reconstruction.

Propeller flaps are effective reconstructive tools for small-to-medium sized defects of the lower limb and a reasonable alternative to free flaps. A major vessel of the lower limb remains undisturbed while raising the flap and the flap donor and recipient areas are addressed in the same operative field. Perforator-based propeller flaps are based on single perforator arising from a major vessel and during rotation of the larger paddle there is a possibility of kink in the venous component leading to congestion of flap. In our modification, one superficial vein of the lower limb namely the great saphenous or short saphenous vein was included in the flap territory to enhance the retrograde or antegrade venous drainage of the flap. We observed, no flap congestion or necrosis in the postoperative period. Also, the patency of the incorporated vein was confirmed using handheld and color Doppler.

Congenital Sub-Mitral Aneurysm: Anesthetics and Surgical Management.

ABSTRACT: A sub-mitral left ventricular aneurysm is a rare condition. It is a congenital outpouching of the left ventricular wall, invariably occurring adjacent to the posterior mitral leaflet. Sub-mitral aneurysm (SMA) has usually been reported as a consequence of myocardial ischemia (MI), rheumatic heart disease, tuberculosis, and infective endocarditis. Nevertheless, there have been few case reports of congenital SMA in India. It usually presents with symptoms of heart failure. We report a rare case of congenital SMA in a 27-year-old young Indian and its successful management through a trans-aneurysmal approach.

Papillary meningioma with prominent flow voids.

This report presents an extremely rare case of papillary meningioma with prominent flow voids and increased perfusion parameters on MRI in a 28-year-old male presenting with headache. This knowledge helped the neurosurgeon to minimise intra-operative blood loss and achieve a favourable post-surgical outcome. Contribution: A rare case of papillary meningioma and its differentiating features from typical meningiomas have been discussed considering its implications for management as well as prognostication to reduce morbidity and mortality.

Myopic Posterior Persistent Fetal Vasculature: A Rare Presentation.

Persistent fetal vasculature (PFV) is a rare ocular developmental disorder resulting from incomplete apoptosis of the embryonic hyaloid vasculature during the in-utero period. Variability in the development and regression of hyaloid vasculature is responsible for the wide range of clinical presentation of the disorder. PFV may manifest as anterior segment abnormalities (cataract, glaucoma, microphthalmia, elongated ciliary process with central traction, retrolental membrane, and shallow anterior chamber), posterior segment abnormalities (vitreous stalk, preretinal membranes, optic hypoplasia, and retinal folds), or with a combined anteroposterior disease. The most common associated clinical feature is leukocoria with microphthalmia and usually unilateral presentation. Most of the cases have poor visual prognosis and present early in childhood. Association with myopia is a very rare and atypical presentation, especially unilateral cases which may present later in life and have a good visual prognosis. Hereby, we present a case of a 27-year-old young adult male with unilateral atypical myopic posterior PFV with anisometropic amblyopia and good functional vision in the right eye.

Clinical, Radiological, and Pathological Correlation of Mandibular Invasion in Carcinoma Bucco-alveolar Complex.

A prospective cross-sectional study was conducted to correlate clinically, radiologically, and pathologically the mandibular invasion in carcinoma bucco-alveolar complex. All biopsy-proven oral cavity cancer cases (64 patients) were assessed clinically and radiologically for involvement of the mandible. Preoperative clinicoradiological findings were compared with postoperative histopathological findings. In our study, oral cancer was 4 times more prevalent in males as compared to females and clinical evaluation was found to be highly sensitive in predicting mandibular invasion. Orthopantomogram showed sensitivity of 66.6% and specificity of 100%. CT scan showed sensitivity of 100% and specificity of 46% whereas MRI showed sensitivity of 54.5% and a specificity of 96%. MRI correlates well with final histopathology in predicting size of tumor. Prevalence of bony invasion in carcinoma oral cavity was 18%. We noted an inverse relation with tumor differentiation and mandibular invasion, and none of the verrucous carcinoma lesions showed mandibular invasion. Association of clinical T and N staging with postoperative histopathology was found to be statistically significant. Despite recent advances in molecular biology, radiological techniques, and newer modalities like visual surgical planning, exact measurement of bone invasion is still challenging. At present, CT scan and MRI along with clinical evaluation are widely used to evaluate mandibular invasion in carcinoma oral cavity, and all these are complementary to each other. The recent progress in tissue engineering technologies and stem cell biology has significantly promoted the development of regenerative reconstruction of jawbone defects.

Correction: Posterior Reversible Encephalopathy Syndrome in the Immediate Postoperative Period of Gastric Cancer.

[This corrects the article DOI: 10.7759/cureus.49388.].

Posterior Reversible Encephalopathy Syndrome in the Immediate Postoperative Period of Gastric Cancer.

A 55-year-old female was referred to the Department of Ophthalmology with complaints of bilateral loss of vision. She had undergone subtotal gastrectomy with gastrojejunostomy and lymphadenectomy for poorly differentiated gastric adenocarcinoma in the antropyloric region the day before. On the first postoperative day, she complained of generalised weakness, drowsiness, altered sensorium, and acute, painless, bilateral loss of vision. Ocular examination revealed visual acuity as no perception of light, bilaterally, and normal pupillary light reflexes. Anterior and posterior segment examination was within normal limits. This clinical presentation of altered sensorium and cortical blindness along with characteristic radiological findings (hyperintensity on T2/fluid-attenuated inversion recovery sequence involving the bilateral parieto-occipital lobe extending in asymmetric fashion to the bilateral cerebellum, brainstem, and thalami predominantly involving the white matter with few areas of diffusion restriction on diffusion-weighted imaging sequence predominantly on the left side with gyriform pattern) confirmed the diagnosis of posterior reversible encephalopathy syndrome (PRES). In cancer patients, PRES has been reported in patients on chemotherapy regimen or two weeks after surgery for gastric cancer. Here, we want to draw attention to the fact that PRES may develop in the immediate postoperative period of gastric cancer surgery, as seen in our case.

Cardiac Computed Tomography Pictorial Equivalent of Angiographic Gooseneck Sign in a Case of Atrioventricular Septal Defect with Cor Triatriatum Sinister.

In the literature, multiple radiological signs of clinically important congenital cardiovascular abnormalities have been described which are named as per the object they resemble. These signs are very useful in learning. The Gooseneck sign is a sign seen in left ventricle catheter angiography in case of an atrioventricular septal defect. This sign has not been demonstrated on a cardiac computed tomography (CT) so far, to the best of our knowledge. We present a case showing cardiac CT pictorial equivalent of angiographic Gooseneck sign.

Plasma Interleukin-33 Cannot Predict Hip Osteonecrosis in Patients With Sickle Cell Disease: A Case-Control Study.

Background Plasma interleukin-33 (IL-33), a cytokine associated with inflammatory and autoimmune disease, has been described to be significantly raised in osteonecrosis of the femoral head (ONFH) and hence was recommended for use as a marker for ONFH. The concentration of plasma interleukin-33 level has not been estimated in any studies conducted in patients with sickle cell disease (SCD); hence, we investigated the levels of plasma interleukin-33 in patients with sickle cell disease with or without ONFH to assess whether it can be used as a marker for the early detection of ONFH in this disease also. Methods Forty-four consecutive patients with sickle cell disease with osteonecrosis of the femoral head and matched controls without ONFH were evaluated for plasma interleukin-33 levels by enzyme-linked immunosorbent assay (ELISA). All patients were confirmed for sickle cell disease using high-performance liquid chromatography (HPLC). ONFH was diagnosed in patients with sickle cell disease using clinical-radiological findings. Univariate and multivariate analyses were performed using the IL-33 level as the dependent variable. Results Plasma IL-33 levels were comparable in 44 patients with sickle cell disease with osteonecrosis of the femoral head as compared with 24 patients with sickle cell disease without ONFH (2.05 ± 4.57 pg/mL versus 1.50 ± 2.89 pg/mL, p-value = 0.590). There was no significant difference in IL-33 levels in different stages of avascular necrosis (AVN). Conclusions Plasma interleukin-33 levels cannot act as a marker of ONFH as were being considered in idiopathic ONFH or ONFH caused by other causes such as trauma and chronic steroid or alcohol usage.

Differentiation between various types and subtypes of intracranial meningiomas with advanced MRI.

Background: Meningiomas are the most prevalent of all intracranial tumours. Although they are mostly benign, about 20% of meningiomas are atypical or malignant. Knowledge of their histologic grade can be clinically useful while planning surgery. Objectives: To differentiate between various grades and subtypes of meningiomas with advanced MR parameters. Method: We assessed the advanced MR imaging characteristics of 27 histopathologically confirmed meningiomas on a 3T MRI, of which 23 were grade I meningiomas (2 fibroblastic, 9 meningothelial, 9 transitional, 3 unspecified) and 4 were grade II/III meningiomas (2 atypical, 1 papillary, 1 anaplastic). Analysis of the ADC, FA, λ1, λ2, λ3 and mean diffusivity was performed using standard post-processing software. Results: The mean size of atypical meningiomas (5.9 cm ± 0.7 cm) was significantly higher (p = 0.038, 95% confidence interval [CI]) than that of typical meningiomas (4.6 cm ± 1.6 cm) with a cut-off value of 6.05 cm (75% sensitivity and 87% specificity). The mean cerebral blood flow (CBF) (ASL) of atypical meningiomas (286.70 ± 8.06) was significantly higher (p = 0.0000141, 95% CI) than that of typical meningiomas (161.09 ± 87.04) with a cut-off value of 276.75 (66.7% sensitivity and 75% specificity). Among the typical meningiomas, transitional subtypes had the lowest ADC. High FA and planar coefficient (CP) values and low λ3 and spherical coefficient (CS) values were seen in fibroblastic meningiomas. Fibroblastic meningiomas also showed the lowest vascularity among typical meningiomas. Conclusion: Tumour size and ASL perfusion are two parameters that could differentiate between typical and atypical meningiomas while ADC, FA, λ3, CP, CS, rCBF and rCBV may be helpful in distinguishing different subtypes of typical meningiomas.

Can diffusion tensor metrics help in preoperative grading of diffusely infiltrating astrocytomas? A retrospective study of 36 cases.

INTRODUCTION: Diffusion weighted imaging and diffusion tensor imaging (DTI) give information about the amount and directionality of water diffusion occurring in a given tissue. Here we study the role of diffusion tensor metrics including fractional anisotropy (FA) and spherical anisotropy (CS) in preoperative grading of diffusely infiltrating astrocytomas. METHODS: We performed DTI in 38 patients with pathologically proven diffusely infiltrating astrocytomas, who were classified into two groups, i.e., 15 patients with high-grade astrocytoma (HGAs, WHO grade III and IV) and 23 patients with low-grade astrocytoma (LGAs, WHO grade II). We measured maximum FA and minimum CS values in all cases from tumor. Histopathological diagnosis was established in all cases. RESULTS: The mean maximum FA values were higher in HGA (0.583 ± 0.104) than LGA (0.295 ± 0.058), while mean minimum CS values were lower in HGA (0.42 ± 0.121) than LGA (0.722 ± 0.061). The difference in the diffusion tensor indices between HGA and LGA was found to be statistically significant with P value of <0.001. Keeping cutoff FA value of 0.4, all HGAs showed higher maximum FA values, and all LGAs showed lower maximum FA values. Also, all HGAs showed minimum CS values less than a cutoff value of 0.6, and all LGAs showed minimum CS values higher than 0.6. CONCLUSION: Diffusion tensor metrics such as maximum FA and minimum CS can help to differentiate HGA from LGA.

Adult onset moyamoya disease: institutional experience.

Moyamoya disease is a progressive steno-occlusive disease of bilateral carotid forks with the formation of fine collateral vascular network and is an angiographic diagnosis. We analyzed case records of 11 patients with "adult-onset moyamoya disease." Six patients presented with intracranial hemorrhage (intracerebral and/or intraventricular) and 5 with focal ischemia. Angiography revealed bilateral Internal carotid artery involvement in 8 patients and unilateral involvement in 3. Posterior cerebral artery involvement was seen in 3 patients. Saccular aneurysm involving posterior circulation was seen in only 1 patient. Although rare, adult-onset moyamoya disease should be considered as one of the causes for intracerebral and intraventricular hemorrhage in adults.

Osteopetrosis in a Patient of Systemic Sclerosis Sine Scleroderma: A Rare Association.

Systemic sclerosis is a connective tissue disorder of unknown etiology. Although it is a multisystemic disorder, skin thickening is considered as a hallmark of the disease. It usually involves the lungs, gastrointestinal, and musculoskeletal systems. However, a rare subset of systemic sclerosis, systemic sclerosis sine scleroderma, is characterized by internal organ involvement and positive serologic markers with the total or partial absence of cutaneous manifestations. We present a rare association of osteopetrosis in a case of systemic sclerosis sine scleroderma, in a 22-year-old male patient, who presented with pulmonary symptoms as his chief complaints, unreported so far in literature.

Information technology-based joint preoperative assessment, risk stratification and its impact on patient management, perioperative outcome, and cost.

BACKGROUND:  Despite negative recommendations, routine preoperative testing practice is nearly universal. Our aim is to bring the healthcare providers on one platform by using information-technology based preanaesthetic assessment and evaluate the routine preoperative testing's impact on patient outcome and cost. METHODS: A prospective, non-randomised study was conducted in a teaching hospital during January 2019-August 2020. A locally developed software and cloud-computing were used as a tool to modify preanaesthesia evaluation. The number of investigations ordered, time taken, cost incurred, were compared with the routine practice. Further data were matched as per surgical invasiveness and the patient's physical status. Appropriate tests compared intergroup differences and p-value <0.05 was considered significant.  Results: Data from 114 patients (58 in routine and 56 in patient and surgery specific) were analysed. Patient and surgery specific investigation led to a reduction in the investigations by 80-90%, hospital visit by 50%, and the total cost by 80%, without increasing the day of surgery cancellation or complications. CONCLUSION: Information technology-based joint preoperative assessment and risk stratification are feasible through locally developed software with minimal cost. It helps in applying patient and surgery specific investigation, reducing the number of tests, hospital visit, and cost, without adversely affecting the perioperative outcome. The application of the modified method will help in cost-effective, yet quality and safe perioperative healthcare delivery. It will also benefit the public from both service and economic perspective.

Three-dimensional alignment of the aggregated myocytes in the normal and hypertrophic murine heart.

Several observations suggest that the transmission of myocardial forces is influenced in part by the spatial arrangement of the myocytes aggregated together within ventricular mass. Our aim was to assess, using diffusion tensor magnetic resonance imaging (DT-MRI), any differences in the three-dimensional arrangement of these myocytes in the normal heart compared with the hypertrophic murine myocardium. We induced ventricular hypertrophy in seven mice by infusion of angiotensin II through a subcutaneous pump, with seven other mice serving as controls. DT-MRI of explanted hearts was performed at 3.0 Tesla. We used the primary eigenvector in each voxel to determine the three-dimensional orientation of aggregated myocytes in respect to their helical angles and their transmural courses (intruding angles). Compared with controls, the hypertrophic hearts showed significant increases in myocardial mass and the outer radius of the left ventricular chamber (P < 0.05). In both groups, a significant change was noted from positive intruding angles at the base to negative angles at the ventricular apex (P < 0.01). Compared with controls, the hypertrophied hearts had significantly larger intruding angles of the aggregated myocytes, notably in the apical and basal slices (P < 0.001). In both groups, the helical angles were greatest in midventricular sections, albeit with significantly smaller angles in the mice with hypertrophied myocardium (P < 0.01). The use of DT-MRI revealed significant differences in helix and intruding angles of the myocytes in the mice with hypertrophied myocardium.

Diffusion tensor mode in imaging of intracranial epidermoid cysts: one step ahead of fractional anisotropy.

INTRODUCTION: The signal characteristics of an epidermoid on T2-weighted imaging have been attributed to the presence of increased water content within the tumor. In this study, we explore the utility of diffusion tensor imaging (DTI) and diffusion tensor metrics (DTM) in knowing the microstructural anatomy of epidermoid cysts. MATERIALS AND METHODS: DTI was performed in ten patients with epidermoid cysts. Directionally averaged mean diffusivity (D(av)), exponential diffusion, and DTM-like fractional anisotropy (FA), diffusion tensor mode (mode), linear (CL), planar (CP), and spherical (CS) anisotropy were measured from the tumor as well as from the normal-looking white matter. RESULTS: Epidermoid cysts showed high FA. However, D(av) and exponential diffusion values did not show any restriction of diffusion. Diffusion tensor mode values were near -1, and CP values were high within the tumor. This suggested preferential diffusion of water molecules along a two-dimensional geometry (plane) in epidermoid cysts, which could be attributed to the parallel-layered arrangement of keratin filaments and flakes within these tumors. CONCLUSION: Thus, advanced imaging modalities like DTI with DTM can provide information regarding the microstructural anatomy of the epidermoid cysts.

Signal changes in cortical laminar necrosis-evidence from susceptibility-weighted magnetic resonance imaging.

INTRODUCTION: Two types of infarcts can be identified depending on the circumstances leading to its generation-infarcts with pannecrosis and infarcts with selective neuronal loss. Cortical laminar necrosis (CLN) can occur due to various etiologies of which infarctions and hypoxia are the commonest. Infarction results in pannecrosis whereas hypoxia and incomplete infarction result in selective neuronal loss with the presence of viable cells, glial proliferations, and deposition of paramagnetic substances. We investigated patients with CLN with susceptibility-weighted imaging (SWI), a technique highly sensitive to even traces of paramagnetic agents or hemorrhagic components. METHODS: We retrospectively reviewed medical records of patients diagnosed with CLN as per standard criterion. Demographic characteristics and etiologies were recorded. Findings in magnetic resonance images including SWI were analyzed. RESULTS: We identified 11 patients with CLN, six males and five females with age range of 4-64 years. Etiologies included hypoxia in two patients and infarction in the nine patients. SWI detected diffuse linear hypointensities along the gyral margins in CLN due to hypoxic ischemic encephalopathy. Linear dot like hypointensities were identified in one patient with infarction. CONCLUSION: CLN due to hypoxic ischemic encephalopathy display linear gyral hypointensities and basal ganglia hypointensities that are identifiable in SWI and may represent mineralization. This might be related to iron transport across the surviving neurons from basal ganglia to the cortex, which is not possible in complete infarction. SWI may be helpful in understanding the pathophysiological aspects of CLN due to complete infarction and hypoxia.

Imaging features in Hirayama disease.

PURPOSE: To evaluate the MR findings in clinically suspected cases of Hirayama disease. MATERIALS AND METHODS: The pre and post contrast neutral and flexion position cervical MR images of eight patients of clinically suspected Hirayama disease were evaluated for the following findings: localized lower cervical cord atrophy, asymmetric cord flattening, abnormal cervical curvature, loss of attachment between the posterior dural sac and subjacent lamina, anterior shifting of the posterior wall of the cervical dural canal and enhancing epidural component with flow voids. The distribution of the above features in our patient population was noted and correlated with their clinical presentation and electromyography findings. OBSERVATIONS: Although lower cervical cord atrophy was noted in all eight cases of suspected Hirayama disease, the rest of the findings were variably distributed with asymmetric cord flattening, abnormal cervical curvature, anterior shifting of the posterior wall of the cervical dural canal and enhancing epidural component seen in six out of eight (75%) cases. An additional finding of thoracic extension of the enhancing epidural component was also noted in five out of eight cases. CONCLUSION: Dynamic post contrast MRI evaluation of cervicothoracic spine is an accurate method for the diagnosis of Hirayama disease.

Evaluation, management, and long-term follow up of vein of Galen malformations.

OBJECT: Vein of Galen malformations (VGMs) are extremely rare intracranial lesions. Clinical presentation and management strategies vary significantly in different areas of the world. The authors report their experience in evaluation, management, and long-term follow up of these lesions in India. METHODS: Between October 1983 and June 2003, 25 patients with VGMs were referred to the authors' institution for evaluation and management. Ten children younger than 2 years of age presented with rapidly increasing head size as the chief complaint. Among 11 children 2 years of age or older, the most common presenting symptom was chronic headache. Four patients who presented during adulthood had chronic headache for many years before presentation. Angiographic evaluation of the lesion was performed in 21 patients. Fifteen patients were treated using endovascular techniques. Injection of the embolic material was performed after induction of systemic hypotension when the flow in the fistula was high. Complete occlusion of the arteriovenous shunt could be achieved in two patients with vein of Galen aneurysmal dilation (100% of patients with this type of malformation) and in five of the six patients with the mural type of malformation (83%). Among patients with the choroidal type of malformation, complete obliteration of the shunt could be achieved in three patients. In three patients with high-flow choroidal malformations, embolization carried out in a single sitting resulted in shunt reduction of nearly 90%. These patients received clinical follow up. CONCLUSIONS: The authors' experience in evaluation and management of VGMs reveals that in areas of the world where access to dedicated specialist care is limited, the clinical presentation of VGMs can differ appreciably from the classic descriptions in the literature. Endovascular management of these lesions results in excellent angiographic and clinical results.

Percutaneous laser disc decompression: clinical experience at SCTIMST and long term follow up.

BACKGROUND: Low backache (LBA) is now increasing in younger population due to misdirected spinal kinetics secondary to improper posture, heavy load lifting and motorbike driving. Hence minimally invasive procedures are increasingly sought after. Among these, PLDD is currently popular and in use. We present our long term follow-up in the use of Nd:YAG laser for PLDD. AIM: To evaluate the efficacy of PLDD in treatment of contained herniation of lumbar discs & long term follow up results. MATERIALS AND METHODS: Forty patients with contained lumbar disc herniation on MRI and who did not respond to 6 weeks conservative treatment were subjected to PLDD. L4-5 disc was treated in 31, L5-S1 in 12 and L1-2 and L3-4 in one each. Nd:YAG laser at 1064 nm was used for the procedure. Total laser energy of 1500-2000 Joules was delivered at the disc space depending upon the size. RESULTS: There was immediate pain relief in 32/40 (80%). According to MacNab criteria good to fair response was seen in 37/40 (92%) and 3 patients (7.5%) responded poorly to this treatment. On follow up which ranged from 1 to 7 years, 34/40 (85%) had pain relief with no need for further treatment. COMPLICATIONS: Significant pain at local puncture site was experienced by 8 (20%), pain during lasing was experienced by one. One patient developed muscular spasm. CONCLUSION: Percutaneous laser disc decompression is a safe, relatively noninvasive and effective treatment modality for contained, nonsequestered, herniated lumbar disc disease in carefully selected patients.