Endoscopic Trans-Nasal Trans-Sphenoidal (TNTS) Approach For Pituitary Adenomas: Our Experience.

Advances in optics, miniaturization, and endoscopic instrumentation have revolutionized surgery in the past decade. Current progress in the field of endoscopy promises to further this evolution: endoscopic telescopes and instruments have improved upon the optical and technical limitations of the microscope, and require an even less invasive approach to the sella. Pituitary surgery is traditionally within the realm of the neurosurgeon. However, since the reintroduction of the transseptal transsphenoidal approach and endoscopic transnasal transsphenoidal approach to the sella turcica for resection of pituitary adenoma, otolaryngologists have been active partners in the surgical management of these patients. Otolaryngologists have lent their expertise in nasal and sinus surgery, assisting the neurosurgeon with the operation. The otolaryngologist has the advantage of familiarity with the techniques and instruments used to gain exposure of the sella turcica by transnasal approach. Hence, the otolaryngologist provides the exposure, and the neurosurgeon resects the tumour. Such collaboration has resulted in decreased rates of complication and morbidity. We hereby discuss our experience of treating 54 cases of pituitary tumour by endoscopic transnasal approach at our hospital.

Rhabdoid meningioma: rapid intraoperative diagnosis on squash smears.

Rhabdoid morphology in tumors refers to resemblance of the cells to rhabdomyoblasts without true skeletal muscle differentiation. The cytological features include abundant eosinophilic cytoplasm, eccentric nuclei, and intracytoplasmic hyaline inclusions. Besides the rhabdoid morphology, cytoarchitectural features of atypical meningioma (four or more mitoses per 10 high-power fields, high cellularity, sheeting architecture, nuclear atypia, and necrosis) are seen in most cases. A case is presented here to highlight the appearance of rhabdoid cells on intraoperative squash smears, for most accurate treatment and close follow-up, as rhabdoid morphology is related to aggressive behavior and poor outcomes.

Natural history of solitary cerebral cysticercosis cases after albendazole therapy: a longitudinal follow-up study from India.

OBJECTIVES: To find out natural course of solitary cerebral cysticercosis (SCC) cases after treating them with 2 weeks albendazole therapy. MATERIAL AND METHODS: All patients with SCC were treated with 2 weeks of albendazole therapy with follow-up radiological scan at 6 months and 2 years. The evolution of lesion was noted as complete resolution, calcification or persistent active. Antiepileptic drugs (AED) prophylaxis was given for 1 year in patients with complete resolution and for 2 years in calcified lesion, respectively. AED was continued in persistent lesion group till it became calcified or resoluted completely. One-year follow-up was done in all after stopping AED. RESULTS: Among 345 cases, 226 (65.5%) had complete resolution with very low seizure relapse rate with 1 year of seizure free period on AED treatment. On the contrary, 105 (30.5%) had calcified lesion with high seizure relapse rate after stopping AED treatment with 2 years of seizure free period. Fourteen patients (4%) could not stop their antiepileptic medication at all because of active lesion. CONCLUSION: Two-third of patients with SCC have favorable outcome with complete resolution and needs short-term AED prophylaxis and the rest one-third requires long AED treatment to prevent seizures.

Sleep seizures versus wake seizures: a comparative hospital study on clinical, electroencephalographic and radiological profile.

BACKGROUND: Epileptic seizures, predominantly or exclusively during sleep had been the focus of attention for many electroencephalographers. Though few epileptic syndromes are associated with sleep seizures (SS) its frequencies in Indian patients is still unknown. AIM: To find out the patterns of epilepsies in patients having SS and compare them with patients having wake seizures (WS). SETTING AND DESIGN: Open label hospital based study. MATERIALS AND METHODS: One hundred and forty-four (13%) patients having predominantly SS were compared with 976 (87%) patients of WS by various clinical, electrophysiological and radiological factors. STATISTICAL ANALYSIS: Chi square test and student T test, using software SPSS (version 10, 1999) was applied to compare various parameters. Relative risk was calculated by 2 x 2 contingency table. RESULTS: The seizure semiology was better defined in patients with WS and GTCS was more common in SS (P=0.001). Wake-electroencephalogram (EEG) was abnormal in significantly (P=0.001) higher number of patients with WS. Symptomatic etiologies were found in more than half patients. Left lobe involvement was more common in patients having SS (P=0.000). After symptomatic, idiopathic generalized and frontal lobe epilepsy were most frequent with SS. Undetermined epilepsy was found in 37 (25.7%) patients with SS. CONCLUSION: Epilepsies associated with SS were less frequent and had symptomatic cause in most cases. Left hemispherical and frontal lobe lesion were more commonly associated with SS. Frontal lobe and idiopathic generalized epilepsy was most frequent in patients of SS. Sleep EEG should always be done in patients with sleep seizures.

Two-tier system of epilepsy evaluation: a useful method for developing countries.

PURPOSE: To test the usefulness of a simplified and clinically oriented, the Epidemiological Classification (EC), in determination of seizure types and appropriate drug selection in epileptic patients at the primary care level. METHODS: The EC was applied to all epileptic patients over 5 years then compared with the currently recommended international classifications of seizures and epilepsy (ICES/ICEES). RESULTS: A total of 1176 patients were enrolled with 2:1 male preponderance and 88% had onset of disease below 30 years of age. Based on EC, 682 (58%) had partial, 333 (28.3%) had generalized and 161 (13.7%) had undetermined seizures semiology. When ICES was applied, seizure typing was same in 86.2%, 68.5% and 26.7% patients of partial, generalized and unclassified seizures respectively. About 87% patients in generalized and partial seizure semiology had no change in selected antiepileptic drug even after the ICES, but 53.6% patients in undetermined group had change in selected AED. Only, 146 patients (12.5%) found to have symptomatic cause for seizure(s) on applying the EC system. After utilizing the ICEES on 1030 patients (87.5%) of "unknown etiology" cases after the EC system, almost 86.5% patients could be classified to a definite etiological class. CONCLUSION: The EC was found useful for determination of seizure type and appropriate AEDs selection at the primary care level. The ICES/ICEES works better at the tertiary care level. This "two-tier" system can be more effective for overall epilepsy management in developing countries with limited facilities.

Comparative study of complex spina bifida and split cord malformation.

OBJECTIVE: To see the difference in clinical profiles, radiological findings and surgical outcome of the group 1 split cord malformation and meningomyelocele (SCM with MMC) from group 2 (SCM without MMC). METHODS: 46 patients of SCM were selected from a total of 138 cases of spinal dysraphism. They were divided into two groups, based on presence or absence of MMC. Group I (SCM with MMC) n =19 patients and Group II (SCM without MMC) n=27 patients. A detail clinical evaluation and MR screening of whole spine of all cases was performed. All patients underwent surgical detethering of cord. After an average follow-up of 1.7 years, the operative results were clinically assessed and statistical significance was calculated. RESULTS: Male to female ratio was 1:09. Mean age of presentation was 3.6 years. Cutaneous markers like tuft of hair, cutaneous haemangioma, etc, had a higher incidence in group II in comparison to group I (50% vs 10.5%). The incidence of motor deficits was significant in group I in comparison to group II (63% vs 40%). The incidences of sensory loss, trophic ulcers, sphincteric dysfunction and muscle atrophy were relatively more common in group I patients, while neuro-orthopedic deformities such as congenital telepes equinovarus (CTEV), scoliosis and limb shortening were more frequent (67%) in group II children as compared to group I (53%). Type I SCM has higher incidence in group I children. Low lying conus were found in 47% patient of group I, while in group II it was noticed in 69%. The associated cranial anomalies like hydrocephalus, ACM and syrinx, were slightly higher in group I patients. At surgery, dysgenetic nerve roots, neural placode, arachnoid bands and atrophic cord were seen mainly in group I. Postoperative complications like, CSF leak, pseudomeningocele and meningitis were more commonly encountered in group I patients. The patients of group II showed better operative outcome compared to group I cases. CONCLUSION: Incidence of SCM with MMC amount to 41% of total SCM cases. Progressive neurological deficit was higher in this group (SCM with MMC) in comparison to the group harboring SCM without MMC. In view of a significant association of SCM in MMC cases, associated with other craniospinal anomalies, a thorough screening of neuraxis (by MRI) is recommended to treat all treatable anomalies simultaneously for desired outcome.

Split cord malformation (scm) in paediatric patients: outcome of 19 cases.

There had been considerable debate regarding the surgical outcome of neuro-orthopaedic syndromes (NOS) and neurological syndromes in cases of split cord malformation (SCM). On retrospective analysis of 19 cases of SCM, thirteen were grouped under (Pang) type I and 6 in type II. Their age ranged from 1 month to 9 years (mean 3.5 years). 14 of these were male children. The NOS without neurological signs was detected in 6 cases where as pure neurological signs without NOS were seen in 8 patients. However, the rest 5 had mixed picture of NOS and neurological dysfunction. Nine of 19 cases presented with cutaneous stigmata, mainly in the form of hairy patch. 18 cases had other associated craniospinal anomalies i.e. hydrocephalus, meningomyelocoele, syrinx, dermoid, teratoma etc. Detethering of cord was done in all cases by removal of fibrous/bony septum. Associated anomalies were also treated accordingly. Follow up of these cases ranged from 6 months to 6 years. Six cases of NOS group neither showed deterioration nor improvement, and remained static on follow up. However, four of 8 children with neurological signs showed improvement in their motor weakness, and 1 in saddle hypoaesthesia as well as bladder/bowel function. In 5 cases of mixed group, two had improvement in their weakness and one in hypoaesthesia, but no change was noticed in NOS of this group as well. Hence surgery seemed to be effective, particularly in patients with neurological dysfunction.