Clinicoradiological study of adult Chiari malformation type 1 patients with emphasis on cerebrospinal fluid peak flow velocity at foramen magnum level.

INTRODUCTION: The aim of this study was to determine the peak cerebrospinal fluid (CSF) flow velocity at the foramen magnum level in adult patients with Chiari type 1 malformation (CM1) and to determine the changes in velocity after posterior fossa decompression. An attempt was also made to determine whether or not CSF flow velocity can be a significant predictor in patients who need surgical intervention. MATERIALS AND METHODS: A prospective longitudinal study was conducted in 32 symptomatic patients of CM1 treated with craniocervical decompression. Only adult patients with age ≥18 years and tonsillar herniation ≥5 mm were included in this study. Clinical and radiological assessment of patients with reference to their CSF flow characteristics was done both preoperatively and after suboccipital decompression. RESULTS: Out of the 32 patients, 30 patients underwent a suboccipital decompression and two patients were treated with a venriculoperitoneal shunt procedure due to gross hydrocephalus. The preoperative mean tonsillar herniation was 10.4 ± 4.64 mm that reduced to 7.35 ± 3.10 mm in the follow up period. Postoperatively, there was also a substantial decrease in the peak CSF velocity at the foramen magnum along with reduction in the extent and size of the syrinx. These changes in CSF velocity correlated with a more normal appearing foramen magnum and an improvement in symptoms. CONCLUSION: Although the selection criteria for surgery are based mainly on the degree of tonsillar ectopia and presenting symptoms, the degree of CSF flow obstruction rather than the degree of tonsillar herniation can better select patients who are most responsive to surgery. An improved CSF velocity profile following surgery in such patients is a useful guide to anticipate a symptomatic improvement.

Serum Magnesium as a Marker of Neurological Outcome in Severe Traumatic Brain Injury Patients.

Hypomagnesemia is postulated as one of the important determinants of outcome following traumatic brain injury (TBI) through its effect on secondary injuries to neurons. AIMS AND OBJECTIVE: The aim of this study was to determine the relationship between serum magnesium level and neurological outcome in patients admitted with severe head injury. MATERIALS AND METHODS: In this prospective study, patients admitted with severe TBI were recruited and dichotomized into low serum magnesium group and normal serum magnesium group based on the initial serum magnesium level. Data were collected regarding age, sex, and Glasgow Coma Scale at admission. Neurological outcome of the patients in these groups was assessed using Glasgow Outcome Scale at 6 months. RESULTS: Seventy-two patients (male = 50, female = 22) with a mean (±standard deviation) age of 42.5 (±12.7) years were studied. Forty-two (58%) patients had low serum magnesium level (<1.3 mEq/L) at admissions. At 6-month follow-up, 81% of patients with poor neurological outcome had low serum magnesium as compared to 19% of patients with good outcome (P = 0.01). Hypomagnesemia was associated with poor neurological outcome (odds ratio = 2.1, P = 0.04, 95% confidence interval = 1.0-8.8) on regression analysis. CONCLUSION: Hypomagnesemia appears to be an independent prognostic marker in patients with severe TBI.

Role of Squash Cytology in Intraoperative Diagnosis of Spinal Lesions.

BACKGROUND: Squash cytology for intra operative diagnosis of central nervous system (CNS) tumors is an immensely important modality. Though its role in brain lesions is unquestionable and has been proven in a number of studies, its utility for spinal lesions is still a grey zone. AIMS: To assess the diagnostic accuracy of squash preparation in spinal lesions and its statistical significance (sensitivity, specificity, positive predictive value, negative predictive value) following histological confirmation. MATERIALS AND METHODS: A total of 57 cases of spinal tumors were taken. May-Grunewald-Giemsa staining (MGG) and Hematoxylin-Eosin (H&E) were done in each one of them. Rest of the tissue was processed for histological diagnosis and results were compared. RESULTS: In our study, histology was taken as the gold standard. By comparing the results, squash preparation had sensitivity of 95.75%, specificity 80.0%, positive predictive value (PPV)95.74%, and negative predictive value (NPV) 80.80%. Schwannoma was found to be the most prevalent tumor in the spine (17/57) in our study, followed by meningioma (13/57). Diagnostic accuracy for schwannoma was fairly high i.e. 92.3%, followed by meningioma (82.35%). Highest diagnostic accuracy was documented in intradural, extramedullary compartment. CONCLUSION: Inspite of having pitfalls and various limitations in case of spinal lesions, squash preparation is a rapid and easy method with fairly high diagnostic accuracy. So it can be reliably used as an intraoperative diagnostic tool in spinal lesions.

Evaluation of Intraoperative Cytological Smears for Diagnosis of Brain Tumors with Special Reference to Immunohistochemistry.

CONTEXT: Brain tumors are heterogeneous group of benign and malignant tumors of glial, meningeal, neuronal, embryonal, and lymphoid origin. Rapid intraoperative diagnosis of the nature of the tumor helps the surgeon to plan the extent of surgery and modify it accordingly. AIMS: (1) To establish the validity and reliability of squash cytology in the intraoperative diagnosis of brain tumors. (2) To correlate with histopathological report and immunohistochemistry (IHC) profile. SETTINGS AND DESIGN: Prospective, observational study. SUBJECTS AND METHODS: prospective, observational study was conducted in the Department of Pathology in collaboration with the Department of Neurosurgery of a tertiary care hospital. One hundred and seven patients with symptomatic or radiologically detected brain tumors were included in the study. Intraoperative squash smears were stained with hematoxylin and eosin and rapid papanicolaou stain. Cytological diagnosis was recorded and communicated to the surgeon. Cytological findings were corroborated with histological findings subsequently. GFAP, Ki-67, and ER-PR IHC were used as additional markers. STATISTICAL ANALYSIS USED: Software used in statistical analysis of our study was MedCalc version 11.6 (Mariakerke, Belgium: MedCalc Software 2011). RESULTS: A total of 107 cases were included in the study. Meningioma was the most common lesion. Overall sensitivity in our study to diagnose benign and malignant tumors was 94.7% and the specificity is 97.6% with positive and negative predictive value of 94.7% and 97.6%, respectively. Diagnostic accuracy was highest in pituitary adenoma. CONCLUSIONS: The combination of meticulous evaluation of clinical, radiological, and cytological findings helps in accurate and rapid diagnosis of brain tumors.

Pneumocephalus following Dorsal Laminectomy: An Unusual Complication.

A 16-year-old male presented at Bangur Institute of Neurosciences Neurosurgery Outpatient Department with history of gradually progressive paraparesis for 5 months associated with stiffness, urinary hesitancy, and urge incontinence for last 2 months. Magnetic resonance imaging spine was done which showed cystic intradural extramedullary space occupying lesion at D4/D5 to D9. Patient had 2 episodes of generalized tonic-clonic seizure on the day 4. Computed tomography scan showed pneumocephalus. Histopathological examination report was that of nonspecific inflammatory cyst.

Traumatic transfers: calibration is adversely affected when prediction models are transferred between trauma care contexts in India and the United States.

OBJECTIVE: We evaluated the transferability of prediction models between trauma care contexts in India and the United States and explored updating methods to adjust such models for new contexts. STUDY DESIGN AND SETTINGS: Using a combination of prospective cohort and registry data from 3,728 patients of Towards Improved Trauma Care Outcomes in India (TITCO) and from 18,756 patients of the US National Trauma Data Bank (NTDB), we derived models in one context and validated them in the other, assessing them for discrimination and calibration using systolic blood pressure, heart rate, and Glasgow coma scale as candidate predictors. RESULTS: Early mortality was 8% in the TITCO and 1-2% in the NTDB samples. Both models discriminated well, but the TITCO model overestimated the risk of mortality in NTDB patients, and the NTDB model underestimated the risk in TITCO patients. CONCLUSION: Transferability was good in terms of discrimination but poor in terms of calibration. It was possible to improve this miscalibration by updating the models' intercept. This updating method could be used in samples with as few as 25 events.

Expression of phosphatase and tensin homolog, epidermal growth factor receptor, and Ki-67 in astrocytoma: A prospective study in a tertiary care hospital.

BACKGROUND: Though the tumor grade is a key factor influencing the choice of therapies, particularly determining the use of adjuvant radiation and specific chemotherapy protocols, role of abnormality in phosphatase and tensin homolog (PTEN) expression and variation in epidermal growth factor receptor (EGFR) labeling index (LI) and Ki-67 LI in survival and clinical outcome have been studied by many researchers in the recent past. AIMS: The aim was to evaluate the expression of PTEN, EGFR and Ki-67 in different grades of astrocytic tumors by means of immunohistochemistry and to judge their role in overall survival (OS). MATERIALS AND METHODS: This study was conducted on 57 cases of different grades of astrocytomas. Expression of PTEN, EGFR and Ki-67 was assessed by immunohistochemistry on formalin fixed and paraffin-embedded sections and the OS was evaluated by Kaplan-Meier survival curves and log-rank test for 2.5 years from the date of primary resection. RESULTS: Most of the tumors (59.6%; 34 cases out of 57) displayed WHO Grade IV features. Distribution of age, EGFR LI and Ki-67 LI expressed strong positive (≥0.5) correlation with the grade of tumors. However, the PTEN positivity was inversely related with the grade of the tumors. Lower WHO grades, lower values of Ki-67 LI, EGFR LI and PTEN positivity were associated with better survival. CONCLUSION: Expression of PTEN, EGFR LI and Ki-67 LI should be combined with the basic histopathological features including WHO grade to predict the prognosis and therapeutic outcome.

Significant modulation of macrophages associated cytokines TNF-α, VEGF and apoptotoic protein Bax, Bcl2 abrogates tumor cells.

T11 target structure (T11TS), a membrane glycoprotein has been documented with anti neoplastic activity in glioma bearing animal model in our lab. In this study, we have evaluated the phagocytic potential, expression of VEGF, TNF-α in T11TS treated and untreated macrophages in all four grades of glioma. The data indicates the significant enhancement of phagocytosis in T11TS treated macrophages of grades I and II glioma. There was significant up regulation in TNF-α and significant down regulation in VEGF expression in T11TS treated macrophages in grade I and II glioma. We also attempted to know any possible apoptotic role of T11TS in tumor cells by comparing Bax and Bcl2 in treated and untreated tumor cells of all four grades. We found significant up regulation in Bax expression and down regulation in Bcl2 expression of grades I and II glioma. The outcome may help in pushing this molecule into pharmaceutical domain.

Thalassaemia intermedia presenting with compressive myelopathy: a case report.

Extramedullary haematopoiesis leading to spinal cord compression is a rare complication of thalassaemia. An interesting case has been reported where a diagnosis of thalassaemia intermedia was made at the age of 35 years in a male patient with no history of blood transfusion, who presented with compressive myelopathy caused by extramedullary haematopoietic tissue in epidural space. The patient recovered after surgical decompression.

Immunomodulatory role of TIITS in respect to cytotoxic lymphocytes in four grades of human glioma.

T11 target structure (T11TS), a membrane glycoprotein has been documented with antineoplastic activity in animal model in our lab. Previously, in animal study we have documented T11TS induced cytotoxic abrogation of tumor cells. Encouraged by these established findings by our group and as prerequisite for clinical trial, this study has been designed to assess the cytotoxic potential of the patient's lymphocytes in in vitro study of autologous human glioma as modulated by T11TS. Meningioma samples were chosen as disease control group. The data produced indicates T11TS induced up regulation of cytotoxicity of T lymphocytes in grade I and II glioma. Significant enhancement of cytotoxic protein, perforin and granzyme suggest cytotoxic death of T11TS induced target tumor. Also, T11TS downregulates the TGF-ß secretion in grade I and II tumor cells. These preliminary findings may help in pushing this molecule into pharmaceutical domain.

Detection of progesterone receptor and the correlation with Ki-67 labeling index in meningiomas.

CONTEXT: Although most of the meningiomas are benign, some of them are associated with a less favorable clinical outcome. The major prognostic question regarding meningiomas is the prediction of recurrence which is largely dependent on the histopathological type, grading, proliferation indices and progesterone receptor status. AIMS: Our study was done to assess the expression of Ki-67 and progesterone receptor (PR) in different histological types, grades, recurrent and non-recurrent meningiomas. MATERIALS AND METHODS: A total of 60 cases were collected over a period of 2.5 years. Hematoxylin and eosin staining was done for histological typing and grading of the tumors. Immunohistochemical staining was done for Ki-67 and PR using standard immunoperoxidase technique and Ki-67 Labeling Index (LI) and PR score was calculated. RESULTS: Mean Ki-67 LI was significantly higher in males versus females, in Grade II versus Grade I, in recurrent versus non-recurrent and in PR-negative versus PR-positive meningiomas. Moreover, considering Grade I and Grade II-meningiomas separately, mean Ki-67 LI was significantly higher in recurrent cases. PR positivity was significantly higher in females versus males, in Grade I versus Grade II and in non-recurrent versus recurrent meningiomas. Correlation between Ki-67 LI and PR expression was also evaluated and a strong inverse correlation was found between Ki-67 LI and PR expression. A strong negative correlation was also established between the values of Ki-67 LI and recurrence-free survival. CONCLUSION: Our results establish that the immunodetection of Ki-67 LI and PR expression in meningiomas provides a practical tool for assessing the biological behavior of meningiomas.