Pediatric Intracranial Hydatid Cyst: A Case Series with Literature Review.

Hydatid disease is an endemic zoonotic disease in many areas of the world. An intracranial hydatid cyst is a relatively rare entity, accounting for only 1-2% of all intracranial space-occupying lesions. Most commonly they are seen in children and young adults. Here, we present 9 cases of pediatric intracranial hydatid cyst operated at Sher-I-Kashmir Institute of Medical Sciences, Srinagar, India, between 2009 and 2015. The mean age of presentation was 11.5 years. The male to female ratio was 5: 4. In 7 cases, a history of contact with pet dogs was present. Seizure was the most common finding, present in 7 cases. Seven patients had solitary cysts and 2 had multiple cysts on presentation. All patients were operated on, and recurrence was observed in 2 patients. The features of this rare disease are retrospectively analyzed in this presentation and the literature is reviewed.

A Rare Case of Spinal Schwannoma in a Child Presenting with Subarachnoid Hemorrhage: A Case Report with Review of Literature.

Pediatric spinal schwannomas/neurofibromas constitute only 2.5%-4% of all pediatric spinal tumors. However, subarachnoid hemorrhage (SAH) because of spinal pathologies is very rare, representing 1.5% of all cases of SAH. Spinal nerve sheath tumors such as schwannomas rarely present with SAH, especially before the appearance of overt signs of spinal cord or root compression. We report a case of dorsolumbar schwannoma in an 11-year-old girl presenting clinically with signs and symptoms mimicking meningitis, but meningeal signs later proved to be due to SAH associated with spinal (D12-L1) schwannoma and hydrocephalus. Mass was excised and ventriculoperitoneal shunt was inserted. In our clinical practice, we may sometimes come across some uncommon diseases with even more uncommon presentations as happened with us at our institute. We must always consider that there is a possibility of SAH owing to silent spinal lesion in patients with angiographic negative intracranial SAH as in this case.

Cranioplasty: Indications, procedures, and outcome - An institutional experience.

BACKGROUND: Cranioplasty, the repair of a skull vault defect by insertion of an object (bone or nonbiological materials such as metal or plastic plates), is a well-known procedure in modern neurosurgery. Brain protection and cosmetic aspects are the major indications of cranioplasty. A retroprospective study was conducted for evaluating the indications, materials used, complications, and outcome of cranioplasty. METHODS: This study was prospective from August 2013 to September 2015 and retrospective from August 2010 to July 2013. In the retrospective study, patients files were retrieved from the mentioned date (August 2010 to July 2013) from the medical records and the findings were recorded. Abstracted data included age at the time of cranioplasty (years), sex (male or female), medical comorbidities (hypertension, diabetes), indications for craniectomy [Road traffic accident (RTA), fall from height (FFH), hit by stone or cricket ball, physical assault, stroke, infection, shell injury, bullet injury, and intraoperative swelling], laterality of cranioplasty (bilateral, unilateral, or bifrontal), time between craniectomy and cranioplasty (weeks), type of graft (autologous or artificial), type of prosthesis if used (methylmethacrylate, titanium), storage of bone flap if used (subcutaneous or deep freezer), operative time (minutes), and complications fallowing cranioplasty. RESULTS: Of the 236 patients included in the study, maximum were in the age group of 21-30 years i.e., 30.93% (n = 73). Mean age of the patients was 33.44 years. A total of 196 (83.05%) were autologous and 40 (16.95%) were artificial. Out of the 40 patients who underwent artificial cranioplasty, 36 (15.25%) had methylmethacrylate graft and 4 (1.7%) had titanium mesh implant. Bone was not preserved in 16.95% (n = 40), preserved in subcutaneous tissue in abdominal wall in 2.54% (n = 6), and preserved in deep freezer in 80.51% (n = 190) of the patients. CONCLUSION: Cranioplasty as a procedure is not without complications; however, if performed properly and at proper time with an aseptic technique, good results are achieved.

A rare case of recurrent primary spinal echinococcosis.

Spinal hydatid disease, though rare, is one of the differential diagnosis of spinal cord compression syndrome especially in endemic areas. Surgery is the treatment of choice but surgery alone is not curative. Adjuvant drug therapy as well as intraoperative prophylaxis are indicated. Despite all measures, the disease has high recurrence rates and overall outcome is still poor. We report a case of 65 year old male with lumbosacral hydatidosis recurring after 13 years.

Apoplexy in sellar metastasis: a case report and review of literature.

Apoplexy in sellar metastasis is very rare with only a few case reports in literature. A case of apoplexy in sellar metastasis from follicular thyroid carcinoma is reported and the literature is briefly reviewed. The patient presented with sudden onset headache and bi-lateral loss of vision following thyroidectomy in a case of follicular carcinoma thyroid with proven sellar metastasis. CT scan showed hyperdense blood in sellar mass suggestive of apoplexy in sellar metastasis. The patient underwent early trans-sphenoidal decompression. Apoplexy in sellar metastasis, although very rare, can be clinico-radiologically indistinguishable from pituitary apoplexy and should be especially considered in the differential diagnosis of patients with known primary neoplastic disease. In view of similar patho-physiological mechanism, sellar metastasis with apoplexy should be managed in a similar manner as pituitary apoplexy.

Missile injury to the pediatric brain in conflict zones.

OBJECT: This study was conducted both prospectively and retrospectively at one center over a period of 8 years. The population consisted of all patients with both an age 18 years or younger and a diagnosed penetrating missile injury (PMI) during the study interval. The authors analyzed factors determining outcome and demographic trends in this population, and they compared them with those in the more developed world. METHODS: Fifty-one patients were the victims of armed conflict, although no one was directly a party to any battle. This mechanism of injury is in strong opposition to data in the literature from developed countries, in which most missile injuries are the result of suicide or homicide or are even sports related. Moreover, all previous studies on the pediatric population have considered only injuries from gunshots, but authors of the current study have included injuries from other penetrating missiles as well. RESULTS: On cross tabulation analysis using the chi-square test, the factors shown to correlate with outcome included the Glasgow Coma Scale (GCS) score, pupillary abnormalities, patient age, hemodynamic status, and bihemispheric damage. On multinomial regression analysis, the two strongest predictors of death were GCS score and pupillary abnormalities. The GCS score and hemodynamic status were the strongest predictors of disability. CONCLUSIONS: There was no difference in the prognostic factors for PMI between developing or more developed countries. Glasgow Coma Scale score, pupillary abnormalities, and hemodynamic status were the strongest predictors of outcome. In conflict zones in developing countries the victims were mostly innocent bystanders, whereas in the more developed countries homicides and suicides were the leading etiological factors.

Subarachnoid hemorrhage in Kashmir: Causes, risk factors, and outcome.

CONTEXT: Kashmir, a snow bound and mountain locked valley, is populated by about 7 million ethnic and non-migratory Kashmiris who have specific dietary and social habits than rest of the world. The neurological disorders are common in Kashmiri population. AIMS: To study the prevalence and outcome of spontaneous intracranial subarachnoid hemorrhage (SAH) in Kashmir compared withother parts of the world. SETTINGS AND DESIGN: A retrospective and hospital based study from 1982 to 2010 in the single and only Neurosurgical Centre of the State of Jammu and Kashmir. MATERIALS AND METHODS: A hospital based study, in which, information concerning all Kashmiri patients was collected from the case sheets, patient files, discharge certificates, death certificates, and telephonic conversations with the help of Medical Records Department and Central Admission Register of Sher-i-Kashmir Institute of Medical Sciences, Kashmir India. STATISTICAL ANALYSIS: Analysis of variance and students T-test were used at occasions. RESULTS: Incidence of SAH in Kashmiris is about 13/100,000 persons per year. SAH comprises 31.02% of total strokes and aneurysmal ruptures are cause of 54.35% SAHs. The female suffers 1.78 times more than the male. Total mortality of 36.60% was recorded against a good recovery of 14.99%. The familial SAHs and multiple aneurysms were also common. Intra-operative finding of larger aneurysmal size than recorded on pre-operative computed tomography (CT) angiogram of same patients was noteworthy. In 493 patients of SAH, the angiography revealed 705 aneurysms. CONCLUSION: Spontaneous intracranial subarachnoid hemorrhage, due to aneurysmal rupture, is common in Kashmir, with worst outcome. Food habits like "salt-tea twice a day", group-smoking of wet tobacco like "Jejeer", winter season, female gender, hypertension, and inhalation of "Kangri" smoke are special risk factorsof SAH, in Kashmiris. The plain CT brain and CT angiography are best diagnostic tools. The preventive measures for aneurysmal formation and rupture seems most promising management of future. The detachable endovascular aneurysmal occupying video assisted micro-camera capsules or plugs may be future treatment.

Clinical outcome in 520 consecutive Danish rectal cancer patients treated with short course preoperative radiotherapy.

AIM: The purpose of this study was to analyse the results of preoperative short course radiotherapy in a consecutive, national cohort of patients with rectal cancer. METHODS: Through a validated, prospective national database we identified 520 Danish patients who presented with high-risk mobile tumours in the lower two thirds of the rectum and were referred for preoperative radiotherapy with 5 x 5 Gy. The inclusion period was 56 months. Radiotherapy data was retrospectively collected. RESULTS: Of the 520 patients, 514 completed radiotherapy and 506 had surgery. Surgery was considered curative in 439 patients. The 3-year local recurrence rate was 4.0% (95% CI 2.5-6.5%) and the distant recurrence rate at 3 years was 18.7% (95% CI 15.4-22.5%). The 5-year disease free survival rate was 40.2% (95% CI 27.0-53.1%) and overall survival 50.4% (95% CI 36.1-63.1%). Most tumours (61%) were classified as T3 or T4 and 41% of the local recurrences occurred in patients with a fixed tumour at surgery. CONCLUSION: This study confirms data from randomised studies that the short course 5 x 5 Gy regime is a feasible treatment for locally advanced rectal cancer even when applied in a population outside clinical trials.

A national cohort study of long-course preoperative radiotherapy in primary fixed rectal cancer in Denmark.

OBJECTIVE: Preoperative radiotherapy has been shown to enable a fixed rectal cancer to become resectable which in turn may result in long-time survival. In this study, we analysed the outcome of long-course preoperative radiotherapy in fixed rectal cancer in a national cohort including all Danish patients registered with primary inoperable rectal cancer and treated in the period May 2001 to December 2005. METHOD: The study was based on surgical and demographic data from a continuously updated and validated national database. In addition, retrospective data were retrieved from all departments of radiotherapy concerning technique of radiotherapy, dose and fractionation and use of concomitant chemotherapy. Outcome was determined by actuarial analysis of local control, disease-free survival and overall survival. RESULTS: A total of 258 patients with fixed rectal cancer received long-course radiotherapy (> 45 Gy). The median age at diagnosis was 66 years (range: 32-85) and 185 (72%) patients were male. The resectability rate was 80%, and a R0 resection was obtained in 148 patients (57% of all patients and 61% of those operated). The 5-year local recurrence rate for all patients was 5% (95% CI: 3-7%), and the actuarial distant recurrence rate was 41% (95% CI: 35-47%). The cumulative 5-year disease-free survival was 27% (95% CI: 22-32%) and overall 5-year survival was 34% (95% CI: 29-39%). CONCLUSIONS: This study is the first population-based report on outcome of preoperative long-course radiotherapy in a large unselected patient group with clinically fixed rectal cancer. Most patients could be resected with the intention of cure and one in three was alive after 5 years.

Gluteal pseudophallus in a male child: A rare cutaneous marker of occult spinal dysraphism.

Congenital midline paraspinal cutaneous markers have been practically linked to the location and nature of neural-tissue lesions. One of the most interesting congenital midline paraspinal cutaneous markers has been the human tail in the lumbosacral region, with underlying spinal dysraphism. Human tails have many shapes and sizes and are usually localized to the lumbosacral region. After a complete neurological examination, the MRI is the most sensitive diagnostic modality to reveal the underlying occult spinal dysraphic state. Surgical excision is aimed at untethering of the spinal cord in symptomatic children and for aesthetic reasons in asymptomatic patients. Here we report an asymptomatic male child with normal external genitilia, whose tail is attached to the gluteal region like an adult phallus and investigations revealed an underlying spinal dysraphic state.

Intradiploic epidermoid causing spontaneous extradural hematoma: case report.

OBJECTIVE: A case of an intradiploic epidermoid tumor leading to spontaneous extradural hematoma is reported. Intradiploic epidermoids are not common intracranial tumors. This is the first reported case of intradiploic epidermoid presenting as a spontaneous extradural hematoma. CLINICAL PRESENTATION: The patient presented with sudden onset of headache and deterioration in the sensorium. A computed tomographic scan revealed a lesion causing erosion of both tables of the calvarium and a mixed intensity extradural hematoma. INTERVENTION: The patient underwent immediate operation, and evacuation of the hematoma and excision of the tumor were performed. CONCLUSION: Intradiploic epidermoid tumors so rarely present with extradural hemorrhage that prophylactic removal cannot be recommended in all such cases. However, in view of the seriousness of the hemorrhage, prophylactic removal may be recommended, especially if the patient, such as a sportsman, child, or elderly person, is prone to injuries.

Effect of midazolam, dexamethasone and their combination on the prevention of nausea and vomiting following strabismus repair in children.

BACKGROUND: Postoperative nausea and vomiting is a common complication following strabismus surgery. This randomized and double-blind study was designed to evaluate the efficacy of midazolam alone or in combination with dexamethasone in reducing the incidence of postoperative nausea and vomiting in children undergoing strabismus repair. METHODS: One hundred ASA I children, aged 4-12 yr, scheduled to undergo elective strabismus surgery, were enrolled. No premedication was given. Anaesthesia was induced with sevoflurane, nitrous oxide and oxygen. After induction, fentanyl 2 microg kg-1 and cisatracurium 0.1 mg kg-1 were administered and an endotracheal tube was inserted. After induction of anaesthesia and before start of surgery, patients were randomly allocated into one of four groups of 25 children each to receive placebo, midazolam 50 microg kg-1, dexamethasone 0.5 mg kg-1 or a combination of midazolam 50 microg kg-1 and dexamethasone 0.5 mg kg-1. Episodes of nausea, and retching and vomiting were recorded during the first 24 h after surgery. RESULTS: The incidence of postoperative nausea was 48%, 32%, 12% and 0% with placebo, dexamethasone, midazolam and the midazolam-dexamethasone combination, respectively. The incidence of vomiting was 52% and 32% with placebo and dexamethasone, respectively; no child vomited with midazolam alone, or with the midazolam-dexamethasone combination. CONCLUSION: Prophylactic midazolam with or without dexamethasone reduces the incidence of PONV in children undergoing strabismus repair.