Effectiveness of deep brain stimulation in Parkinson's disease treatment with Single-center experience in Pakistan.

Objective: To assess the effectiveness and accuracy of deep brain stimulation in Parkinsonian Disease (PD). Methods: This study was a descriptive prospective study, and patients were treated at Neurospinal and Cancer Care Institute Karachi, from February 1, 2016, to June 30, 2020. We had 21 cases of parkinsonian disease. Inclusion criteria was Idiopathic Parkinson's disease, marked motor fluctuations against the response to dopaminergic therapy, UPDRS-III scores, which is 30 or higher, with a duration of disease of five years or longer, developing dyskinesia while the exclusion criteria was patient with known comorbid or active psychiatric disease. Results: Mean age of patient was 64 years. The standard deviation was 1.11697. The male patients' mean, median and mode had a standard deviation of 0.3. For the duration of disease, the mean was 1.4, the median 1 (5-6 years) and mode one. The standard deviation was 0.51177. The primary symptoms' mean was 2.2857, the median was 2.0, and the mode was two (tremor). The mean on medication (age) was 2 (45-49), and the median and mode were the same. Conclusion: Deep brain stimulation (DBS) is an effective treatment option for a carefully selected patient. DBS improves tremors, dyskinesias, rigidity, motor fluctuations and bradykinesia. DBS is unlikely to benefit Autonomic dysfunction, cognitive disorders, hypophonia, and postural instability. Although it is an expensive treatment compared to lesioning or gamma knife, it is reversible.

Glomus jugulare tumors treatment by gamma knife radiosurgery: A single center study.

Objective: Glomus jugulare tumor are benign vascular tumors and surgical resection is almost impossible. We have treated these tumors by Gamma knife radiosurgery and share our experience. Methods: This study was conducted at the Neurospinal and Cancer Care Institute, Karachi from January 2010 to May 2020. Thirty-four patients with glomus jugulare tumors treated with gamma knife radiosurgery were included in the study. The comprehensive clinical and demographic characteristics of all patients were collected through a manually designed questionnaire. Computed tomography, digital subtraction angiography and magnetic resonance imaging were used to make the diagnosis. Data was incorporated and analyzed by SPSS version 26. Results: A total of 34 patients were included in the study of which 16(47%) were males and 18(53%) were females with first follow up after 6-month up to two year clinical and radiological follow-up. The mean age of the patients was 42.5±13.5 with a minimum age of 20 years and maximum age of 65 years. The KPS scale was 2.09±0.45 and the volume of the tumor was 33.8±22.5 cm3. The improvement was shown in 27 patients of which 14 were males and 13 were females showing insignificance post radiation change. Of all 34 patients, the outcome was recorded as 3(9%) for excellent, 22(64%) for good, 6(17%) for fair and 3(9%) were poor results. Conclusions: Gamma Knife radiosurgery is a safe and effective primary therapy and salvage therapy for residual and recurrent cases of glomus jugulare and tympanicum tumors.

Volumetric Modulated Arc Therapy (VMAT): A modern radiotherapy technique - A single institutional experience.

OBJECTIVE: To evaluate VMAT plans for conformity and homogeneity of radiation dose to the target in order to share our experience as a pioneering institute to use VMAT technology in Pakistan. METHODS: Since December 2014 to January 2018, 530 patients of various anatomical sites were treated by VMAT technique at Neurospinal Cancer Care Institute (NCCI) Karachi Pakistan. ERGO++ planning system (Version 1.7.2) was used to develop VMAT plans with single or multiple arcs by the rotation of couch and gantry. The plans were evaluated by calculating Conformity Index (CI) and Homogeneity Index (HI) and critical organ (OARs) doses of individual tumor sites. RESULTS: The average CI of various sites was 1.4 (range: 1.0-2.0) and average HI of various sites was 1.20 (range: 1.07-1.374), respective critical organ doses were adequately achieved. CONCLUSIONS: VMAT treatment planning technique showed good conformal and homogeneous target coverage with sparing of organs at risk and reduced treatment delivery time. With these features, safety of VMAT technique may allow its routine clinical use, though it is still under investigation in many areas.

Orbital dermatofibrosarcoma protuberans with intracranial extension preceded by recurrent leiomyoma of the orbit: a case report.

INTRODUCTION: Dermatofibrosarcoma protuberans is a rare, locally aggressive cutaneous tumor of intermediate to low-grade malignancy. COL1A1-PDGFß translocation is specific to dermatofibrosarcoma protuberans, where the abnormally fused COL1A1-PDGFß gene directs formation of an abnormal combined (fusion) protein that researchers believe to ultimately function like the platelet-derived growth factor-beta protein. CASE PRESENTATION: In this report, we present a case of a 63-year-old Asian man with dermatofibrosarcoma protuberans of the right orbit with intracranial extension. He had a prior history of recurrent leiomyomas at the identical site. He underwent near-total en bloc resection of the tumor through a wide craniectomy with a 6 cm rim of the frontal scalp, allowing the tumor to be resected en bloc, leaving negative margins. Microscopically, the tumor comprised spindle cells with mild nuclear atypia and a low mitotic index embedded in a spiraling pattern of decussating fascicles consistent with dermatofibrosarcoma protuberans. The lesion was positive for CD34 and BCL2. Following resection, the patient was started on imatinib mesylate therapy (800 mg/day). CONCLUSIONS: We propose that platelet-derived growth factor, which has been implicated in the progression of leiomyomas by augmenting mitogenesis, may have acted in an autocrine manner to cause cell division, which may have led to the development of dermatofibrosarcoma protuberans in our patient. Further research is imperative to find certain molecular associations between the discussed soft tissue tumors. Also important is the effective utilization of platelet-derived growth factor receptor kinase inhibitors to prevent transformation to any platelet-derived growth factor-driven tumor, which in our patient was a dermatofibrosarcoma protuberans.

Multisession stereotactic radiosurgery for large benign brain tumors of >3cm- early clinical outcomes.

OBJECTIVE: To evaluate the clinical outcome of linear accelerator based multisession stereotactic radiosurgery (SRS) for large benign brain tumors of >3cm. METHODS: Between June 2009 and May 2011, 35 patients having large benign brain tumors of >3cm (≥15 cm3) were treated by multisession stereotactic radiosurgery. This retrospective study was carried out at Neurospinal & Medical Institute Karachi. There were 17 (48.6 %) males and 18(51.4 %) females. Median age was 36 years (range: 13-65 years). Median target volume was 49.4 cm3 (range: 15-184 cm3). The median marginal dose was 25 Gy (range: 20-27.5Gy) prescribed to a median 75% isodose line (range: 65-100 %). Median number of 5 fractions were used ranging 3-5 fractions. RESULTS: All the patients tolerated treatment very well. 21 (58.3%) patients had remarkable clinical improvement of neurological symptoms, 14 (38.9%) patients had stable symptoms, and only one patient had transient worsening of symptoms. No permanent neurological damage or radiation injury was seen. Radiologically, 9 (25.7%) patients achieved reduction in size of the tumor, 26(74.3 %) patients were having stable disease, and overall control rate was found to be 100 %. Median follow-up time from the end of SRS was 6.4 months (range: 1-22.5months). CONCLUSION: Linear accelerator based multisession stereotactic radiosurgery for large benign brain tumors of >3cm is effective and well tolerated.

Alpha 1-adrenoceptor subtypes mediating adrenergic vasoconstriction in kidney, one-clip Goldblatt and deoxycorticosterone acetate-salt hypertensive rats.

We characterised the functional alpha 1-adrenoceptors involved in mediating adrenergic vasoconstrictor responses in kidney of two-kidney one-clip (2K1C) Goldblatt and deoxycorticosterone acetate (DOCA)-salt hypertensive rats. In sodium pentobarbital-anaesthetised rats, frequency- and dose-dependent renal vasoconstrictor responses were obtained by direct electrical renal nerve stimulation, close renal arterial administration of phenylephrine (PE), and methoxamine. Administration of amlodipine, a dihydropyridine calcium channel antagonist (bolus dose of 200 and 400 micrograms/kg and an infusion of 50 and 100 micrograms/kg/h, respectively) and the alpha 1-adrenoceptor antagonist 5-methylurapidil (5 micrograms/kg plus 1.25 micrograms/kg/h and twice this dose) suppressed renal nerve-, PE-, and methoxamine-induced vasoconstrictions 14-70% (p < 0.05-0.001) in 2K1C Goldblatt and DOCA-salt hypertensive rats. The alpha 1B-adrenoceptor alkylating agent, chloroethylclonidine (5 micrograms/kg plus 1.25 micrograms/kg/h and twice this dose) caused significant attenuation (p < 0.001) of renal nerve-induced vasoconstriction by 19-23% in DOCA-salt hypertensive rats but did not affect PE- and methoxamine-induced vasoconstriction in either 2K1C Goldblatt or DOCA-salt hypertensive rats. In contrast, in 2K1C Goldblatt rats vasoconstrictor responses were potentiated by renal nerve stimulation and methoxamine. The data show that the functional renal postjunctional alpha 1-adrenoceptors on the vasculature of both hypertensive models are primarily of the alpha 1A-subtype, as reflected by their sensitivity to amlodipine and 5-methylurapidil. Moreover, an interaction appears to occur between the alpha 1-adrenoceptor subtypes at renal vessels in 2K1C Goldblatt hypertensive rats.

Embolic brain infarction: a rare complication of thoracic outlet syndrome. A report of two cases.

The thoracic outlet syndrome is known to cause brachial neuropathy. Pressure on the subclavian artery causing post-stenotic dilatation with intraluminal thrombosis is not a common complication. This may lead to antegrade embolisation and ischemic changes in the upper limb. In right sided thoracic outlet syndrome the thrombus may extend retrogradely. From this an embolus may detach to the right hemisphere of the brain resulting in left sided hemiplegia. This is a rare but serious complication from a neglected, relatively benign, curable condition. This report describes two cases of a right sided thoracic outlet syndrome due to cervical rib compression with retrograde embolisation.

Effect of acute and subacute treatment of clonidine on blood pH, PCO2 and PO2 in mice.

1. Measurements were made on blood pH, PCO2 and PO2 in mice after a single injection and following five weeks continuous clonidine hydrochloride treatment. 2. A single injection of clonidine hydrochloride exerts no effect on blood pH, PCO2 and PO2 but five weeks of continuous clonidine hydrochloride treatment lowers the blood pH and PCO2 and raises blood PO2, suggesting acidosis has taken place. 3. The acidosis may be attributed to rebound hypertension as a result of withdrawal of clonidine treatment.