Serum cytokines in astrocytic brain tumors: a prospective study.

BACKGROUND: Gliomas are the most aggressive form of brain tumors responsible for the majority of brain cancer related deaths. Interleukin (IL)-6, 10 and tumor necrosis factor (TNF)- α are tumor specific proteins that are expressed in gliomas. This study aims to estimate the pre- and postoperative levels of serum markers of these cytokines to evaluate any bearing with its grade and volume. METHODS: Prospective analysis of 80 patients of newly-diagnosed gliomas of any grade was carried out. Pre- and postoperative blood samples day one, one month and at 3rd month of surgery was taken and levels of IL-6, 10 and TNF- α measured and matched with 20 healthy controls. RESULTS: Of the 80 patients, 3 patients had pilocytic astrocytoma, 4 had ganglioglioma, 9 had oligodendroglioma, 17 had diffuse astrocytoma, 5 had anaplastic astrocytoma while 43 had glioblastoma. Preoperative levels of IL-6 and TNF- α was found to be markedly raised in high grade gliomas. Positive correlation was seen between IL-6 with the grade of tumor and high-grade tumors were seen to be more significantly correlated with IL-6. However, preoperative IL-10 in both low and high grade of gliomas did not show any correlation with the volume and grade of tumor. CONCLUSION: High level of IL-6 and TNF-α in peripheral blood in patients of high-grade gliomas provides clue to the invasiveness of the disease which can be useful for understanding the premorbid development of tumor and perhaps extrapolating to ongoing tumor response to treatment.

Complex spinal dysraphism: myelomenigocele associated with dorsal bony spur, split cord malformation type I, syringomyelia, lipoma and tethered cord.

Variations in split cord malformation (SCM) are known. However, association of SCM type I with myelomeningocele along with same level dorsal bony spur has not been described previously. We report a 1-year old male child who presented with these findings with associated syringomyelia, lipoma and tethered cord.

Nasopharyngeal rhinosporidiosis with intracranial extension masquerading as juvenile angiofibroma: an unusual entity.

Rhinosporidiosis is a chronic fungal inflammatory disease prevalent in India and Sri Lanka. Its manifestations are mostly nasal and extranasal lesions are relatively rare. Occasional atypical presentations of this disease lead to diagnostic dilemma. Herein we report on a case of nasopharyngeal rhinosporidiosis having extensive involvement of paranasal sinuses along with intracranial extension which mimicked radiologically as juvenile nasopharyngeal angiofibroma. To our knowledge, this is the first reported case of rhinosporidiosis having intracranial extension. We discuss the pathology, treatment and briefly review the literature of this rare disease.

T cell lymphoblastic lymphoma/leukemia within an adrenocorticotropic hormone and thyroid stimulating hormone positive pituitary adenoma: A cytohistological correlation emphasizing importance of intra-operative squash smear.

We present a rare case of primary pituitary T cell lymphoma/leukemia (T-LBL) in association with adrenocorticotropic hormone (ACTH) and thyroid stimulating hormone (TSH) expressing pituitary adenoma in a 55-year-old woman highlighting the importance of intra-operative squash smears examination. The patient presented with complaints of headache, diminution of vision and recent onset altered sensorium. MRI revealed a mass lesion in the sellar-suprasellar region with non-visualization of pituitary gland separately, extending to involve adjacent structures diagnosed as invasive pituitary macroadenoma. Intra-operative tissue was sent for squash smear examination. The cytology showed a tumor comprising of sheets of immature lymphoid cells intermixed with clusters of pituitary acinar cells with many mitoses and tingible body macrophages. A diagnosis of presence of immature lymphoid cells within the pituitary was offered and differentials of infiltration by lymphoma cells from systemic disease versus primary central nervous lymphoma-like lymphoma arising in the pituitary adenoma were considered. Later paraffin section examination and immunohistochemistry corroborated with the squash findings and a final diagnosis of primary pituitary T cell lymphoma/leukemia in association with ACTH and TSH expressing pituitary adenoma was made. To date, only six cases of primary pituitary T cell lymphomas, including three T-LBL cases, have been reported. This is the seventh case and first one additionally describing cytohistological correlation and importance of intra-operative cytology.

Intraventricular Tuberculoma in a Child: A Rare Location.

Intracranial tuberculoma is an uncommon presentation of tuberculosis, and its occurrence in an intraventricular location is very rare. It is usually confused with glioma, parasitic cyst, and craniopharyngioma. Few case reports exist in the literature on this entity. We report a case of tuberculoma at the foramen of Monro in a 7-year-old child and review the literature in terms of diagnostic dilemma.

The Department of Neurosurgery, G. B. Pant Hospital, New Delhi.

The history of the prestigious Department of Neurosurgery, Gobind Ballabh Pant Institute of Medical Education Institute and Research, New Delhi, a leading tertiary care centre, is presented. Its eminent faculty and outstanding patient care attracts patients and students from all over the country.The patients opt for this institution to get a standard of care that may be comparable with the highest standards prevalent; and, the students achieve their goal of getting excellent education in Neurosurgery at par with the best institutes of the world. The department has, therefore, over the years, established its place in the country as a premier training facility and an epitome of medical excellence.

Ventriculoperitoneal shunt tube infection and changing pattern of antibiotic sensitivity in neurosurgery practice: Alarming trends.

INTRODUCTION: Infection associated with a ventriculoperitoneal shunt is a severe complication with a high morbidity and substantial mortality. There are no guidelines to choose antibiotics in case of shunt infection. Most surgeons use antibiotics of their choice whereas limited centres follow their own antibiotic policy. An alarming increase in antibiotic resistance has led to rising morbidity and mortality. MATERIALS AND METHODS: This was a retrospective analysis of patients who underwent ventriculoperitoneal shunt surgery between January 2010 and December 2015 at our institution. Shunt tubes and cerebrospinal fluid were sent for culture and sensitivity in patients who were suspected clinically of having shunt tube infections. The processing of the samples was done by standard techniques, and the identification of the organism along with its sensitivity pattern was performed using Vitek 2 system. RESULTS: A total of 1186 ventriculoperitoneal shunt surgeries were performed during this period at our institute in patients of all age groups. There were 757 (63.8%) male and 429 (36.2%) female patients. A total of 156 samples of patients were sent for culture and sensitivity during this period, out of which 79 (50.6%) samples had growth of an organism either in the cerebrospinal fluid [36 (23.1%)], shunt tubing [16 (10.2%)], or in both [27 (17.3%)]. The most common organisms grown in the cultures were Staphylococcus aureus [65 (82.3%)] or coagulase-negative Staphylococcus [22 (25.3%)] in the Gram-positive group and Escherichia coli [17 (21.5%)] in the Gram-negative group. Over the last 6 years, the sensitivity pattern of both Gram-negative and Gram-positive bacteria has shown alarming decreasing sensitivity for various commonly used antibiotics. CONCLUSION: Ventriculoperitoneal shunt infection has become an important concern in cases of hydrocephalus. Due to the development of a high proportion of antibiotic resistance, we recommend an empirical therapy of antibiotic therapy for prophylaxis and suspected infection in ventriculoperitoneal shunt surgery.

Endovascular Occlusion of Cervical Internal Carotid Artery Pseudoaneurysm in a Child Treated by N-Butyl Cyanoacrylate: A Rare Case Report.

We report a rare case of spontaneous extracranial cervical internal carotid artery (ICA) pseudoaneurysm in a female child aged 3 years who presented with a swelling in the neck which had bled following an attempted incision as it had been thought to be an abscess. A CT angiogram and an MR angiogram were not very conclusive to diagnose the exact site of origin and the morphology of the aneurysm. Digital subtraction angiography revealed a dissecting pseudoaneurysm of the right extracranial cervical ICA. The right ICA was ending as a pseudosac, and the right cerebral circulation was filling up through the right posterior cerebral artery. To minimize the radiation exposure, a microcatheter was placed inside the diagnostic catheter. The aneurysm sac was occluded using N-butyl cyanoacrylate since there was no distal flow to the brain from the artery beyond the aneurysm. It was a safe, effective and cheaper alternative to open surgery or to other endovascular management options available. Not all neck swellings are abscesses, and they should be examined and evaluated to exclude a vascular cause.

Occiput/C1-C2 fixations using intra-laminar screw of axis - A long-term follow-up.

BACKGROUND: The surgical management of the craniocervical junction is challenging. Rigid posterior fixation of occiput/C1-C2 can be performed using a variety of surgical techniques including C2 pedicle/pars interarticularis, transarticular and intralaminar screw fixations. METHODS: Forty-one patients were treated with occipital plate/C1 lateral mass and C2 intra-laminar screw fixations for basilar invagination and congenital atlantoaxial subluxation, post-traumatic instability, tuberculous and rheumatoid arthritis-associated atlantoaxial dislocation. Out of forty-one, thirty-six patients had bilateral crossing intra-laminar screws and five had ipsilateral laminar screw fixation bilaterally. RESULTS: Follow-up was done in thirty-nine patients from 6 months to 8 years (mean: 21 months) and solid osseous fusion could be achieved in all (100%). One patient was lost to follow-up and another patient died of a cause unrelated to surgical technique. Pre-operative and post-operative Neurosurgical Cervical Spine Scale showed improvement in all patients having features of myelopathy. There were no neurological or vascular complications. However, nine patients had posterior laminar breach, eight had anterior laminar penetrations and three had wound infections. One patient had transient bulbar palsy and one patient had hardware failure in the form of avulsion of the midline occipital plate. CONCLUSIONS: Intra-laminar screw fixation is a safe alternative to transarticular and transpedicular/pars interarticularis fixation of C2 with advantage of having no risk of injury to vertebral artery and comparable biomechanical and pull-out strength.

Rigid variety occiput/C1-C2-C3 internal fixation in pediatric population.

PURPOSE: The purpose of this study was to review our experience of rigid internal fixation of craniovertebral junction in pediatric population. A new technique of reduction of basilar invagination with atlantoaxial dislocation is described. To the best of our knowledge and available scientific literature, this technique has not yet been described in younger patients. METHODS: We have managed 27 children by rigid variety of occiput/C1-C2-C3 internal fixation of various craniovertebral junction pathologies. All patients were subjected to thin cuts of computed tomography with 3D reconstruction for selecting appropriate rigid construct. Eight children had occiput-C2, 3 had occiput-C2-C3, and 16 had C1-C2 hardware constuct. One patient of C1-C2-plate fixation had section of C2 nerve root ganglia. Basilar invagination with atlantoaxial dislocation was reduced by new distraction/compression techniques. RESULTS: Improvement in clinical features and correction of deformity with solid hardware construct were seen in all patients. Follow-up period ranged from 5-72 months. One patient was lost to follow-up, and one case died of compression of vertebral artery at C1 lateral mass. Patients of myelopathy had recovery rate of 90.9%. Hardware failure was seen in one patient, and wound infection was observed in two cases. CONCLUSIONS: Rigid variety of occiput/C1-C2 internal fixation is a safe and effective method in the management of variety of craniovertebral pathologies in pediatric population. This new technique of reduction of basilar invagination with atlantoaxilal dislocation from posterior approach may alleviate the need of high morbity associated with surgical procedure like transoral odontoidectomy in younger patients.

Internal carotid artery agenesis presenting with ruptured Acom aneurysm: Rare case report.

Developmental anomalies of internal carotid artery (ICA), being rare entities, are mostly asymptomatic by themselves because of good collateral supply. However, when present with other associated intracranial anomalies requiring treatment, there can be catastrophic consequences, if special attention is not paid to this condition. We present a case of 36 years old male, who reported to our emergency department with complaints of headache and loss of consciousness. He was diagnosed as a case of ruptured anterior communicating aneurysm with subarachnoid hemorrhage and agenesis of left ICA with trans-cavernous anastomosis. He underwent clipping of aneurysm and was discharged uneventfully. This report highlights the importance of skillful microsurgical clipping in extremely high-risk conditions, in contemporary era of hybrid neurosurgeons.

Endoscopic observations of blocked ventriculoperitoneal (VP) shunt: a step toward better understanding of shunt obstruction and its removal.

OBJECTIVES: Most of our understanding of ventriculoperitoneal (VP) shunt blockage (ventricular end) is based on in vitro studies of blocked VP shunts. Not much information is available regarding the in vivo changes that occur in the tube and in the surrounding ventricle. The primary aim of our study was to observe and analyse these changes, directly, through the endoscope, in patients with blocked shunts undergoing an endoscopic third ventriculostomy (ETV). Based on these findings, we have also suggested criteria for safe removal of the VP shunt tube following ETV. MATERIAL AND METHODS: ETV was performed with standard technique in patients with blocked VP shunt. The ventricular end of the shunt tube was inspected through the endoscope, for changes in ventricle linings as well as in the shunt tube. These changes were correlated with the age of the patient, etiology of HC, type or make of the shunt tube, duration of shunt placement to ETV and the CSF findings. RESULTS: Fifty-three patients of blocked VP shunt underwent ETV from July 2006 to April 2010. Thirty patients had Chhabra (CH) V P Shunt (Surgiwear, India) and 23 had ceredrain (CD) shunt (Hindustan Latex, India). The age of the patients ranged from 2 months to 60 years (mean--13.33 years.). Various causes of hydrocephalus (HC) included congenital hydrocephalus (aqueductal stenosis) in 18 patients, post-meningitis hydrocephalus (PMH) in 32 cases, neuro-cysticercosis (NCC) in 2 patients and intraventricular haemorrhagic (IVH) in 1 patient. Clinical and radiological improvement occurred in 33 (62.21%), and 24 (45%) patients, respectively. Freedom from shunt was attained in 20 (38%) patients. The changes around the shunt tube were seen in 41 (77%). Hyperaemia and neovascularised ependyma was seen in 20 (37%) and 15 (28%) patients. Encasement of the tube was seen in 41%. Ependymal growth and neovascularised shunt tubes were noticed in 15% each. Choroid plexus blocking the tube was seen in only four cases (7%). VP shunt was revised in 14 patients (26.4%). Patient with infective etiology had more changes (p < 0.005). Age, CSF findings and make of shunt tube had no relation with endoscopic observations (p< 0.02). CONCLUSIONS: ETV has a role in shunt failures. It can offer patient a chance of shunt free life. Endoscopic observation of shunt tube and ventricle can unfold several interesting in vivo findings pertaining to shunt obstruction. Shunt should only be removed if there are no adhesions and neovascularisation.

Gender Differences in Perceived Stress among Neurosurgeons: A Cross-Sectional Study.

Purpose: Surgeons are subjected to enhanced levels of work-related stress and women are likely to face unique challenges due to sub-optimal representation. The present study was conceived with a primary objective to study the gender differences faced by surgeons and neurosurgeons in particular. The secondary objective was to assess the correlation between the various stress inducers and busters of normal working and daily life and the mental state of neurosurgeons. Methods: The study was a cross-sectional, multi-centric study in which a structured questionnaire was sent to neurosurgeons through various neurosurgical forums of the country. A total of 93 complete responses were included in the study. The questions were broadly divided into four themes, demographic working data, stress inducers, stress busters, and questions to reflect the mental state of the respondent. Results: There were 74 males and 19 females in the study, with an average age of 39.34 ± 8.57 years. Statistically significant gender differences were noted in rating the out-patient department (OPD) hours, lectures and seminars, performing and assisting surgeries, attending conferences and working in the intensive care unit (ICU), with women scoring lower than men for these activities. There were no significant gender differences in the mental state of the respondents. A strong correlation was found between scoring for performance and assisting of surgery and the mental state questions, and a strong negative correlation was noted between music, playing games, going to the gym, practicing yoga and the mental state questions, indicative of a protective effect. Conclusions: There was no significant gender differences in the perceived stress levels among neurosurgeons. Women appeared more comfortable with certain normal activities of working. A strong negative correlation was reported for activities such as music, playing games, yoga, and going to the gym, indicating a protective effect.

Treatment Dilemma of Latrogenic Pseudoaneurysm of the Intracavernous Internal Carotid Artery in Young Girl Following Transnasal Transsphenoidal Surgery: A Case Report.

Epistaxis following transnasal transsphenoidal (TNTS) removal of pituitary adenoma can be massive and life-threatening. The intracranial source of bleeding is usually the intracavernous segment of the internal carotid artery (ICA) or adjacent branches. Injury to the cavernous ICA can lead to pseudoaneurysm (PA) or fistula formation. Management of PA is different from saccular aneurysms. A timely diagnosis and adequate management can restore vessel integrity and prevent associated morbidity. A young patient of growth hormone-secreting pituitary adenoma, who underwent microscopic TNTS excision of the tumour, presented with massive epistaxis. Pseudoaneurysm of the cavernous ICA was initially not seen on computed tomography angiography and was later diagnosed on digital subtraction angiography. The attempted management of PA with coils without stent could not stop aneurysm recurrence. The management of such complicated PAs is discussed, and a literature review is done regarding epistaxis in growth hormone secreting adenoma.

Bilateral open-door expansive laminoplasty using unilateral posterior midline approach with preservation of posterior supporting elements for management of cervical myelopathy and radiculomyelopathy--analysis of clinical and radiological outcome and surgical technique.

BACKGROUND: The purpose of this study was to evaluate bilateral open-door cervical laminoplasty for management of cervical canal stenosis secondary to multisegmental cervical spondylosis and ossified posterior longitudinal ligament. The importance of unilateral posterior approach with preservation of posterior supporting element is emphasized. METHODS: Thirty-four patients had expansive laminoplasty. Posterior tension band consisting of nuchal ligaments and supraspinous and interspinous ligaments was secured. Paraspinal deep extensor muscles attached to one side of spinous process were also preserved. Hydroxyapatite-collagen spacers were positioned between split laminae in midline and secured with Ethibond. All patients had features of myelopathy with weakness, hypertonia, clonus, and hyperreflexia in both upper and lower limbs. Bladder and bowel involvement was seen in 11.7% and sexual dysfunction in 5.8%. Preoperative dynamic study of cervical spine, MRI, and/or CT were done in all patients and compared with postoperative studies to see the efficacy of the surgical procedure. RESULTS: Preoperative and postoperative neurosurgical cervical spine scale was used to compare results in relation to age, sex, duration of symptoms, neurosurgical cervical spine score, bladder, bowel, and sexual abnormalities. Elderly patients, lower neurosurgical score, signs and symptoms of more than 2 years, and bladder, bowel, and sexual dysfunction had poorer outcome. Complications were few. All patients had adequate diameter of spinal canal postoperatively. Cervical alignment and range of motion of segment subjected to laminoplasty were preserved satisfactorily in follow-up. CONCLUSIONS: Bilateral open-door expansive laminoplasty using unilateral posterior midline approach provides preservation of posterior supporting tension band and excellent reconstruction of spinal canal. This technique also does not compromise contralateral paraspinal muscles attached to spinous process.