Gamma knife radiosurgery for recurrent anaplastic ependymoma with intracranial disseminations: a case report

Intracranial ependymomas are relatively rare type of gliomas which have high recurrence rates after multimodal therapy with surgery, fractionated radiation therapy and chemotherapy. We report the case of a 15-year-old girl with recurrent anaplastic ependymoma [WHO grade III] who underwent multiple surgical excisions for a right temporoparietal tumor in 1998, followed by fractionated radiation therapy and chemotherapy. Eleven years after initial treatment, follow-up imaging of the brain demonstrated tumor recurrence with multiple intracranial dissemination. Clinically, the patient was asymptomatic. We managed her with gamma knife radiosurgery at our center. The recurrent ependymoma along with four intracranial disseminations were defined with gamma plan and a prescription dose of 16 Gy was delivered to the mean target volume of 1.56 ml [range 0.159 - 5.7 ml] with a mean isodose line of 54.3% [range 50 - 65%]. Images on post-radiosurgery follow-up at 21 months revealed complete remission of the recurrent ependymoma and significant decrease in size of all disseminations

Management of maxillary molar undergoing buccal bone resorption due to orthodontic banding

The consequences of injudicious use of orthodontic braces may vary from mild periodontal problems to severe loss of the attached periodontal tissues. In this case the patient had undergone orthodontic treatment. Though her appearance improved after the orthodontic treatment, but tooth # 16 which was banded and used for anchorage showed complete crestal and apical bone dehiscence in the buccal region. The patient came with the complaint of discomfort and inability to chew on the right side of maxilla. On intraoral examination, unusual calculus was seen deposited on the gums. X-ray showed resorption of buccal roots of tooth # 16. The patient was treated endodontically for the same tooth as it was grossly carious with exposed pulp chamber but incomplete root canal treatment. The buccal canals showing resorption were disinfected and overfilled to an extent that GP points became visible in the buccal sulcus. Raising the flap, the affected roots were cleaned and planed and the extruded GP cut and the roots resected and sealed with glass ionomer cement to encourage reattachment of periodontal apparatus. After 9-month of recall, patient is performing well with improved periodontal attachment and firmly standing tooth in the socket

Limb salvage in critical ischaemia

125 patients with critical limb threating ischaemia are reviewed. The majority were male smokers. 92% involved the lower extremity. Thirty primary amputations were done as these presented with fixed and extensive gangrene with an operative mortality of 36.8%. 23% had acute onset of ischaemia while 77% presented with chronic ischaemia. Thromboembolectomy salvaged 80% of the acute ischaemia cases. The chronic ischaemia groups was predominantly secondary to atherosclerotic arterial occlusive disease and not Thrombo Angitis obliterans contrary to the local belief. Femeropopliteal [13] was the most common bypass procedure performed. Aorto-Bilateral femoral [4], popliteo tibial [4] and extra anatomic bypasses [4] were the next common procedures. Overall in the bypass procedures there was 88% immediate graft patency and 84% limb salvage. Aggressive attempts towards limb salvage is recommended

Carotid endarterectomy

This is the first reported series of carotid endarterectomies from Pakistan. Of the 68 patients that presented with symptoms suggestive of cerebro-vascular insufficiency, 59 were evaluated noninvasive using bi-directional Doppler and photo-plethysmography. Accuracy of non invasive testing was 75%. Six carotid endarterectomies were performed with no operative mortality and a single minor residual neurologic deficit suggesting that the procedure can be performed locally with a reasonable degree of safety

Isolated aneurysm of the iliac artery

Iliac artery aneurysms are one tenth as common as abdominal aortic aneurysms. When present they are usually atherosclerotic, and occur in associated with abdominal aortic aneurysms [AAA]. Isolated mycotic iliac artery aneurysms are even more uncommon. One such case of an Isolated Mycotic right iliac artery aneurysm is presented with a brief review of the literature

Abdominal wall defects: use of internal supporting materials

The Use of Internal Supporting Material as a strengthening device in case of abdominal wall defects is reported in 19 cases, spread over a period of 6 years. Marlex Mesh was used in 14 cases, Teflon Mesh in 2, Mersilene Mesh in 2 and Prolene Mesh in one. The criterion chosen for mesh repair are [a] multiple previous failed herniorrhaphies [b] two defects in the linear alba existing simultaneously with relatively normal aponeurosis in between or [c] any incisional hernia more than 2cms in transverse diameter. The operative technique is presented. The mean follow up is 28 months with success rate of 88%. There were two failures in this series. The causes of failures are discussed

Endoscopic sphinctero papillotomy

The first case of Endoscopic Sphincteropapillotomy in Pakistan [in a patients with Retained Common Bile duct stones] is presented with a brief review of the subject