Role of Diffusion and Perfusion Magnetic Resonance Imaging in Predicting the Histopathological Grade of Gliomas - A Prospective Study.

CONTEXT: Gliomas are the most common brain tumors. In addition to conventional magnetic resonance imaging (MRI) techniques, a variety of new techniques offers more than the anatomic information. The new MRI techniques include perfusion-weighted imaging (PWI) and diffusion-weighted imaging (DWI). AIMS: The aim of this study is to assess the sensitivity, specificity, predictive value, and accuracy of diffusion- and perfusion-weighted MRI in the preoperative grading of gliomas. SETTING/DESIGN: The study was conducted in the Department of Neurosurgery, Pathology, and Radiodiagnosis, Sher-e-Kashmir Institute of Medical Sciences, Kashmir, India, which is the only tertiary care neurosurgical center in the state. It was a prospective study. PATIENTS AND METHODS: Thirty-one consecutive patients with gliomas were included in the study. All the patients were evaluated by a standard conventional contrast-enhanced study on Siemens 1.5 Tesla MRI. In addition to the standard MRI, diffusion- and perfusion-weighted MRI were also performed. The histopathological grading of the tumor was done as per the WHO classification of 2007. The sensitivity, specificity, predictive value, and accuracy of diffusion- and perfusion-weighted MRI in determining tumor grade were calculated. Comparison was done between PWI, DWI findings, and WHO histopathological grading. ANALYSIS METHOD: The statistical analysis was done using the Statistical Package for the Social Sciences, and receiver operating characteristic curves were used to estimate sensitivity, specificity, and accuracy. RESULTS: The overall sensitivity of PWI (with regional cerebral blood volume cutoff of 1.7) in the preoperative assessment of high-grade gliomas was 82.6% and specificity was 75%, the positive predictive value (PPV) was 90.48%, and the negative predictive value (NPV) was 60%. The overall accuracy was 80.65%. In case of DWI, the sensitivity was 69.57% and the specificity was 75%, and the PPV and NPVs were 88.8% and 46.15%, respectively. The overall accuracy was 71%. CONCLUSION: Our results clearly show higher accuracy of diffusion- and perfusion-weighted MRI in assessment of glioma grade as compared to conventional MRI. This information can prove very useful for the operating neurosurgeon in preoperative assessment and surgical planning. Postoperatively, the neuropathologist can also benefit from such information.

P53 and Ki-67 Expression in Primary Pediatric Brain Tumors: Does it Correlate with Presentation, Histological Grade, and Outcome?

CONTEXT: Pediatric brain tumors are a vexing problem for the neurosurgeon due to the fragile patient cohort. We attempt to find parameters which can help us to treat and prognosticate these patients in a better way. AIMS: This study aims to correlate clinical presentation, outcome, and histological grade with P53 and Ki-67 expression in primary pediatric brain tumors. SETTING DESIGN: This was a prospective, observational study. PATIENTS AND METHODS: Forty-seven patients with primary brain tumors in the age group 0-18 years were included in this study. Clinical presentation was noted. Patients were operated, and specimen was sent for histopathological and immunohistochemistry examination for p53 and Ki-67. The WHO classification of 2007 was used to grade the tumors. Follow-up was done at 3 and 6 months with Glasgow outcome score. Expression of p53 and Ki-67 in different tumors was correlated with clinical presentation, tumor grade and outcome. ANALYSIS METHOD: Statistical Package for Social Science version 17. P < 0.05 was considered statistically significant. RESULTS: There was statistically significant correlation between high tumor grade and high Ki-67 levels (P = 0.000). On post hoc analysis, there was a significant difference between p53 levels in Grade 1 and Grade 4 tumors. There was statistically significant correlation between neurological deficit and higher p53 levels (P = 0.040). There was statistically significant correlation between poor outcome and higher p53 (P = 0.034) and Ki-67 (P = 0.000) levels at 3 months follow-up which continued at 6 months. CONCLUSIONS: From this study, we conclude that p53 and Ki-67 expression in pediatric brain tumors is associated with poor outcome and correlates with tumor grade. Moreover, p53 expression correlates with neurological deficit.

Chronic subdural hematomas: single or double burr hole-results of a randomized study.

AIM: To analyze the analysis of recurrence rates of single versus double burr holes in patients with subacute and chronic subdural hematomas. MATERIAL AND METHODS: The study was a prospective randomized controlled trial on patients with subacute and chronic subdural hematomas. Collections with membranes or septae were excluded from the study. A written consent was taken from the patient or patient party after explaining the procedure. A total of 254 patients were enrolled in the study over a period of 18-months in the Department of Neurosurgery, Sheri-Kashmir-Institute of Medical Sciences, Srinagar, Kashmir. RESULTS: Recurrence rates in single and double-burr-hole groups were 6.15% and 4.83% respectively, which was not statistically significant. CONCLUSION: Most of the subdural hematomas can be dealt by single burr-hole drainage.

Is hypothyroidism and hypogonadism an issue after aneurysmal subarachnoid hemorrhage-an institutional experience?

BACKGROUND: The incidence of hypopituitarism in aneurysmal subarachnoid hemorrhage ranges from 0% to 45%. Also the screening for hypopituitarism in survivors of aneurysmal SAH is not a routine. This has led to a controversy in the management of such patients. OBJECTIVES: The aim of the study was to evaluate the endocrine profile of our patients who had presented with aneurysmal SAH. PATIENTS AND METHODS: This was a prospective study conducted over a period of three years in patients of aneurysmal subarachnoid hemorrhage. The serum samples for levels of free T4, free T3, TSH, prolactin, FSH, LH and testosterone were analyzed at the time of admission and at a follow-up period between 9-12 months. Patients with known endocrine abnormalities, liver or kidney disease and patients with hemodynamic abnormalities were excluded from the study. Abnormalities in levels were noted and a comparative analysis of the hormone levels between the 2-time periods was done. A total of 73 patients were enrolled in the study. RESULTS: Serum prolactin was raised in 17.80% (13/73) and FSH, LH and testosterone levels were reduced in 12.32% (9/73) of patients in the acute phase at admission. After 9 months follow-up, serum prolactin normalized in all except one patient and in all the males, testosterone level increased significantly. Two patients (3%) developed central hypothyroidism on follow-up. CONCLUSIONS: Chronic hypothyroidism and hypogonadism is not an issue in aneurysmal SAH patients.