Unlocking the Battle: Clipping vs. Endovascular Therapy for Shunt-Dependent Hydrocephalus After Aneurysm Rupture - An In-Depth Institutional Analysis.

AIM: Subarachnoid haemorrhage (SAH) often leads to shunt-dependent hydrocephalus (SDH). This study compares microsurgical clipping and endovascular therapy (EVT) for managing SDH in SAH patients with hydrocephalus. MATERIAL AND METHODS: A retrospective study conducted from July 2018 to December 2022 included 67 SAH patients with acute hydrocephalus. Data on demographic, clinical, and radiological parameters, such as age, gender, GCS scores, Hunt and Hess grade, Fischer score, EVD duration, complications, Omaya reservoir placement, CSF drainage, and outcomes, were collected. Statistical analyses, including univariate analysis and stepwise logistic regression, identified significant risk factors for shunt dependence. RESULTS: Among the 67 patients, 33 underwent microsurgical clipping, and 34 received EVT. Spasmolysis reduced shunt dependency, while early EVD placement correlated with reduced shunt dependence (p = 0.002). The Omaya reservoir helped manage meningitis but was associated with shunt dependency (p = 0.04). Perioperative infarct was a significant risk factor for shunt dependence on multiple logistic regression analysis (p = 0.05). No significant difference was observed in patient outcomes between the two treatment groups. However, EVT patients had shorter ICU and hospital stays. CONCLUSION: This study underscores that clinical vasospasm management through spasmolysis may reduce shunt dependency. Overall, both microsurgical clipping and EVT offer similar long-term outcomes and efficacy to prevent shunt dependence, but EVT has the advantage of shorter hospital stays. These findings provide crucial insights for clinical decision-making and patient care in SDH following SAH.

Spontaneous thrombosis and calcification of giant cavernous carotid artery aneurysm: A rare case and management insights.

Background: Giant cavernous carotid artery aneurysms (>25 mm) are rare (3-5%), with some prone to spontaneous thrombosis (10-20% complete). We present a unique case of one of the largest aneurysms spontaneously thrombosing and calcifying. Case Description: A 57-year-old with persistent right-sided headaches had a substantial hyperdense mass in the right middle cranial fossa, eroding petrous bone. Magnetic resonance imaging and digital subtraction angiography revealed a giant cavernous segment fusiform aneurysm of the right internal carotid artery (ICA) with spontaneous thrombosis and distal ICA occlusion. Collateral circulation maintains the cerebral blood supply. Despite anatomical challenges, conservative management was chosen due to the patient's stability. Conclusion: This case highlights the complex interplay between thrombosed giant aneurysms and affected vessels, with unique features such as cross-flow, calcification, and bone erosion. We advocate conservative management for stable cases, supported by literature, emphasizing vigilant follow-up. This expands the spectrum of aneurysm presentations and encourages further research into their dynamics.

Navigating Uncharted Waters: Comparative Analysis of Clinical Progression and Outcomes in Vestibular Schwannoma Patients with Papilledema and without Hydrocephalus, Versus Those without Papilledema and Hydrocephalus: A Comprehensive Institutional Insight.

BACKGROUND: Papilledema's association with hydrocephalus (HCP)-linked larger vestibular schwannoma (VS) is established but cases lacking concurrent HCP require further investigation. METHODS: This retrospective comparative observational study, conducted from July 2018 to July 2023, examined 120 VS patients undergoing surgery. Patients were categorized into Group 1 (papilledema without HCP) and Group 2 (no papilledema or HCP), with comprehensive data analyzed. RESULTS: In this study, Group 1 (14 patients with papilledema) and Group 2 (106 patients without papilledema or HCP) were compared. Group 1 was younger (mean age 27.21 ± 11.73 years) than Group 2 (mean age 54.66 ± 11.44 years). Both groups had similar symptom durations and tumor detection times. Group 1 had increased vascularity (P = 0.001), elevated cisterna magna protein levels (P = 0.001), and a higher incidence of neurofibromatosis 2 (P = 0.003). They also experienced longer surgeries (P = 0.001) and more blood loss (P = 0.001), leading to extended postoperative complications. Group 2 showed improved postsurgery visual outcomes (P = 0.001), better Glasgow Outcome Scores (P = 0.001), enhanced facial nerve preservation (P = 0.002), and improved hearing on follow-up (P = 0.003). Logistic regression analysis highlighted prolonged surgery duration (P = 0.057) and papilledema (P = 0.0001) as significant factors influencing visual improvement. CONCLUSIONS: Patients with VS require preoperative fundoscopy evaluation due to potential visual loss and papilledema, even without HCP. Early treatment initiation enhances visual and hearing outcomes. Meticulous surgery is vital given the lesion's hypervascular nature and adherence to surrounding structures. Preoperative embolization may aid in preserving neurovascular structures. In developing countries with higher blindness rates, judicious noncontrast computed tomography brain evaluation is crucial for timely detection and treatment initiation of lesions like VS.

Non-trivial ground and excited state photophysics of a substituted phenol.

5-(tert-Butyl)-2-hydroxy-1,3-isophthalaldehyde (5-tBHI) shows solvent dependent single or dual emission. The photophysics of 5-tBHI has been studied in a variety of solvents and the results were compared with that of the methyl derivative of the probe as well as the 5-tBHI anion. It has been found that the intramolecular H-bonded conformer of 5-tBHI predominantly exists in non-polar solvents, and undergoes facile excited state intramolecular proton transfer (ESIPT). On the other hand, a dynamic equilibrium can be found in polar, protic solvents, even in the ground state, except in water. NMR analyses confirm the loss of aromaticity of the probe in the ground state via anion formation, in equilibrium with the solvent mediated intermolecularly H-bonded state, in neat polar protic solvents like methanol. The proton transfer process, either intramolecularly or intermolecularly, was found to be of the order of 1 ps, and even faster than the instrumental resolution in the case of water. The current finding provides important insights on the photophysics of this small, substituted phenol.

Endovascular glue embolization of the medial posterior choroidal artery aneurysm: A case report and a literature review.

Background: The medial posterior choroidal artery (MPCA) aneurysm is extremely uncommon. Thus yet, just a few cases have been reported. Due to the deep position, narrow lumen, fragile walls, and extensive tortuosity, both endovascular and microsurgical procedures are strictly limited. A case study of successful endovascular glue embolization of a left MPCA aneurysm and a literature review is included in this report. Case Description: A 17-year-old female arrived at our institution 2 days after suffering a major intraventricular hemorrhage with a minor subarachnoid hemorrhage. Digital subtraction angiography revealed a left MPCA aneurysm. The patient underwent a successful endovascular glue embolization and had a favorable functional outcome. Conclusion: Endovascular glue embolization yielded favorable clinical and angiographic results in MPCA aneurysms where microcatheter access and maneuverability are challenging.

Cultural adaptation and psychometric evaluation of Childbirth Experience Questionnaire 2 in Karnataka state, India.

BACKGROUND: Women's birthing experience is a sensitive indicator of the quality of childbirth care and can impact the physical and mental health of both women and their neonates. Negligible evidence exists on Indian women's birth experiences and-to the best of authors' knowledge-no questionnaire has been tested in India for measuring women's birthing experiences. This study aimed to test the construct validity and reliability of the Kannada-translated Revised Childbirth Experience Questionnaire. METHODOLOGY: A cross-sectional survey was carried out among postnatal women (n = 251, up to six months postpartum, with a live healthy neonate) who had given birth at a public or private health facility using the Kannada-translated CEQ2 in two districts of Karnataka. Data were collected at participants' homes after seeking written informed consent. Model fit was determined by Confirmatory Factor Analyses. RESULTS: The 4-factor model of the CEQ2 showed good fit after deletion of one item (item 8, subcategory "participation") with CMIN = 1.33; SRMR = 0.04; GFI = 0.92, CFI = 0.98, TLI = 0.99, RMSEA = 0.037 and p value 0.002). The Cronbach alpha values were acceptable for the four subscales (0.92, 0.93, 0.97, 0.91) as well as for the overall 21-item scale (0.84). CONCLUSIONS: The Kannada-translated CEQ2 is a reliable tool to measure the childbirth experiences among Kannada-speaking women and can serve as a reliable ongoing evaluation of women's birth experiences.

Removal and identification of a subconjunctival parasite by light and scanning electron microscopy.

Background: Ophthalmic dirofilariasis is an uncommon zoonotic parasitic infection caused by species of Dirofilaria, a dog tapeworm that is transmitted to human by mosquitoes. Man is a dead-end host for the parasite. Ophthalmic involvement is rare and includes periorbital, subconjunctival, subtenon, and intra-ocular involvement. We report the removal of a subconjunctival worm and identification by light microscopy (LM) and scanning electron microscopy (SEM). Purpose: : A 62-year-old female presented with complaints of redness, discharge, and foreign body sensation with difficulty in opening eyes in the left eye for the last 3 days. The patient is a non-vegetarian. On examination, her best corrected visual acuity in both eyes was 20/20. On slit lamp examination, there was a long, thin, round, coiled white subconjunctival live worm in the left eye superiorly. The rest of anterior segment evaluation, intra-ocular pressure, and fundus was normal in both eyes. The parasite was removed under local anesthesia from subconjunctival space [Video]. External surface morphology under LM revealed fine transverse cuticular striations with tapered cephalic and caudal ends. Uterus was long and coiled with indistinguishable masses inside. The finding was also confirmed by SEM. Synopsis: A subconjuctival parasite was removed and identified as Dirofilaria repens by characteristic LM and SEM findings. Highlight: Dirofilaria species may lodge in many tissues of human bodies including eye and adnexa. Dirofilaria is a natural parasite of carnivorous animals, mostly dogs, cats, and foxes.[1] The most common mode of transmission to human is usually by bite of mosquitoes like Culex and Aedes, which are considered as vectors, and it is often thought that parasitemia is because of accidental conduction.[1] Simple surgical removal of the worm is curative. After removal, the worm should be visualized directly under LM. All the internal structures of the transparent worm could be seen and compared with those under SEM.

Malignant Peripheral Nerve Sheath Scalp Tumor: A Short-Term Institutional Experience with Literature Review.

Malignant peripheral nerve sheath tumor (MPNST) of the scalp is rare. These lesions are associated with neurofibromatosis type 1 (NF1), but patients had been reported without NF1 also. We tried to analyze the difference between the clinical course and outcome of the patient with MPNST having stigmata of NF1 and without it. We included five patients treated over 3 years between July 2018 and July 2021 with diffuse scalp MPNST. Two of these five patients with MPNST of the scalp had neurocutaneous stigmata of NF1. Three were female and two males with an average age of 38.40 ± 18.48 years-the youngest with NF1 being a 19-year-old female. We found dull aching pain as the most typical complaint in all patients and a repeated episode of generalized seizure in one patient. In these cases, two patients with NF1 have highly vascular tumors and attained large sizes greater than 30 cm. These two cases required preoperative digital subtraction angiography (DSA) and embolization with n-butyl acrylate. Total excision of the tumor was done in all patients with radiotherapy. Metastases within 1 year were noted in two patients with NF1, and one of these two succumbed to her illness. The rest of the three patients without NF1 are under follow-up with no evidence of disease with a maximum follow-up of 2 years. Large MPNST (size > 20 cm) are rare and reported to have been associated with and without NF1. Patients with scalp MPNST with NF1 can achieve larger size with fast progression of tumor size and higher chances of recurrence and metastases.

Spontaneous Cervicothoracic Extradural Hematoma with Rare Presentation in Pediatric Patient with Stroke-Like Features in Association with COVID-19, Presenting as Management Dillemma.

Presentation of cervico-thoracic extradural hematoma in pediatric age is rare with stroke-like features. Its association with COVID-19 in the active stage of the disease had not been reported and its management presents a management dilemma as COVID-19 with stroke-like features. A 14-year-old boy was referred to our institute with complaints of sudden-onset upper and middle back pain, associated with loss of sensation below the middle of the back, sudden progressive weakness of both lower limbs (power 0/5) and upper limbs (power grade-2/5), and incontinence of urine, following bouts of vomiting 12 days back. There was no history of trauma, bleeding diathesis, etc. Blood investigation was suggestive of leukocytosis, and RT-PCR test for COVID-19 was positive with raised D-dimer, serum ferritin, and C-reactive protein. MRI spine was suggestive of cervicothoracic extradural hematoma extending from C5-D3 level and compressing the spinal cord. The patient refused surgical decompression and was managed conservatively, following which he improved with power grade in limbs to 4/5. Surgical decompression is the treatment of choice but the patient can sometimes improve on medical management. Association of COVID-19 with spontaneous cervicothoracic extradural hematoma had not been reported earlier in the active stage, but its role in inducing vasculopathy and increased chances of bleeding at the uncommon site had been reported in the literature, and it may precipitate such cervical epidural hematoma.

Management dilemma in a rare case of pituitary apoplexy with akinetic mutism in the setting of ruptured junctional brain aneurysm: A case report and literature review.

Backgound: Pituitary apoplexy is associated with stroke, head injury, and brain tumors. Still, its presentation due to the ruptured aneurysm is rare and its presentation with akinetic mutism has not been reported. Case Description: The patient in the present study is 21-year-old female who presented in our emergency department in an altered sensorium with Glasgow comma score (GCS) E2V1M1. She was intubated and resuscitated. Routine blood investigations, lipid profile, and hormonal studies were normal. Initial noncontrast computed tomography (NCCT) head revealed subarachnoid hemorrhage in the interhemispheric fissure and evidence of bleeding in the pituitary gland. Magnetic resonance imaging (MRI) brain was soon done, which showed an infarct and hemorrhage in the pituitary gland; there was an evidence of an infarct in the bilateral medial frontal gyrus, basal ganglia, and supplementary motor area. MR arteriography revealed an aneurysm at the left A1-anterior communicating artery (Acom) junction directed superomedially with diffuse spasm in a bilateral anterior cerebral artery. Pterional craniotomy was done with clipping of the aneurysm and evacuation of blood clots from the interhemispheric fissure and pituitary gland. Histopathology features suggestive of the non-functioning pituitary tumor with interspersed hemorrhagic necrosis. Intraarterial vasodilation with microcatheter injection was given, but vasospasm did not improve. Postoperatively, Levodopa was started. She used to track objects in front of her eye and started nodding her head in "yes and no fashion," with power in limbs improved to 3/5 at 6 months of follow-up. Conclusion: Pituitary apoplexy with ruptured A1-Acom junction aneurysm with nonfunctioning pituitary macroadenoma is rare, and its presentation with akinetic mutism has not been reported. As there is scarce literature suggesting an association between pituitary apoplexy and ruptured aneurysm, it is challenging to comment regarding its pathogenesis. Although akinetic mutism generally has a poor prognosis, it may respond to Levodopa with a better outcome.

Post Traumatic Hydrocephalus in Indian Subpopulation: An Institutional Experience.

AIM: To identify subgroups of cases with ventriculomegaly who will benefit from the cerebrospinal fluid (CSF) diversion procedures, n patients with post-traumatic hydrocephalus (PTH), and to identify the risk factors for its development to minimize its occurrence. MATERIAL AND METHODS: We analyzed 500 head injury cases who were admitted over a one and a half year period in our institute with PTH, to assess them for treatment benefit by CSF diversion procedures and associated risk factors for its development. The patients were assigned to one of three groups: Group 1 had ventriculomegaly with periventricular lucency (PVL), and raised intracranial pressure (ICP) 2.1% (10/500). Group 2 had ventriculomegaly with PVL, and normal opening pressure 1.75% (7/500) and Group three had no ventriculomegaly 95.75% (483/500). RESULTS: The incidence of radiological PTH in this study was 3.4% (17/500), and it developed after an average interval of 16.43 ± 23.7 (SD) in Group 1 and 19.76 ± 8.9 (SD) weeks in Group 2. Lower Glasgow Coma Score (GCS) (p < 0.001), decompressive craniotomy (p < 0.001) and requirement for prolonged ventilatory support (p < 0.001) were significantly associated with the development of PTH. Significantly better results were found in cases with PTH and high opening CSF pressure (? 15 mmHg) on Lumbar puncture (p < 0.001). Decompressive craniotomy cases required significantly more shunt revisions compared to conservatively managed cases (p < 0.05). CONCLUSION: CSF diversion procedures help to improve ventriculomegaly cases with documented evidence of raised ICP but not in cases without raised ICP. The subgroup of PTH, which cannot be treated by CSF diversion procedures, can only be managed by minimizing many of the risk factors for its development. In cases with severe head injury, a low GCS, and prolonged ICU stay, decompressive craniotomy should be used judiciously. The duration of mechanical ventilation should be minimized and combined with necessary measures to improve GCS.

Comparative Analysis of Clipping and Endovascular Therapy Outcomes in the Treatment of Ruptured Distal Anterior Cerebral Artery Aneurysms.

AIM: To compare the outcomes of distal anterior cerebral artery (DACA) aneurysm treatment using endovascular therapy (EVT) and surgical clipping, and to assess their risk factors. MATERIAL AND METHODS: We retrospectively sampled and analyzed 31 patients treated for ruptured Distal anterior cerebral artery (DACA) aneurysms from a larger sample of 250 patients treated for ruptured aneurysms between July 2018 and July 2021. The outcomes of patients who underwent clipping and EVT were compared using chi-square tests. T-tests were used for univariate analysis and a logistic regression analysis was used to determine the risk factors affecting outcomes. RESULTS: Of the 31 patients, 20 were treated with clipping and 11 with EVT. Patients treated with EVT had a mean age of 35.45 ± 6.66. The mean age of the clipping group was 44.4 ± 6.94 years (p=0.002). Intraoperative rupture was significantly more common in the clipping group (p=0.025). There were no significant differences in the postoperative incidence of vasospasm or hydrocephalus (p=0.12). Modified Rankin Scale scores (p=0.017) and Glasgow Outcome Scale scores (p=0.02) both at discharge and 6-month follow-ups were significantly better in the EVT group than in the clipping group. Length of stay in the Intensive Care Unit (ICU) was 9.27 ± 2.6 days following EVT and 23.60 ± 6.29 following clipping (p=0.001). Age (p=0.0136), Hunt and Hess grade (p=0.02), and the occurrence of intraprocedural rupture (p=0.009) were found to significantly affect outcomes. CONCLUSION: The outcomes of EVT were better than those for clipping and required a shorter stay in the ICU and the hospital. This may be partially attributable to the dual-trained neurovascular surgeon who performed the procedures. Older age, poorer Hunt and Hess grades, and intraoperative aneurysm rupture adversely affected outcomes.

Comparative outcome of endovascular embolization with microsurgery in managing acute spontaneous cerebral hemorrhage in pediatric patients, an institutional experience.

OBJECTIVES: A few previous studies have reported the role of embolization with curative intent in the treatment of the early phase of a spontaneous cerebral hemorrhage in pediatric patients, and its efficacy needs to be compared with surgery at the same time risk factors for hemorrhage following early embolization in such patients need to be evaluated. METHODS: From a pool of 80 pediatric (< 18 years) who had undergone treatment for ruptured AVM with hemorrhage at our center between July 2018 and July 2022, we identified 36 patients with spontaneous bleeding due to AVM. Out of which, 20 were treated solely by embolization (group 1), while the remaining patients were treated surgically (with and without adjuvant embolization) (group 2). RESULT: Spetzler-Martin's grading of the lesion suggested seven lesions < 3 and 13 lesions ≥ 3 in the embolization group. Similarly, seven lesions were < 3 and nine ≥ 3 Spetzler-Martin grade in the surgery group. Incomplete embolization was associated with hemorrhage in two patients treated with curative intent and four patients treated with embolization as adjuvant in the surgery group (p = 0.01). On follow-up, 18 patients in the embolization group and 12 in the surgery group had Glasgow outcome scores ≥ 4 (p = 0.273). CONCLUSION: In the pediatric age group, incomplete embolization is the significant risk factor for hemorrhage in AVMs treated after a hemorrhagic stroke. Embolization with curative intent is as effective as surgery in treating such lesions as adjuvant embolization with careful patient selection.

COVID19-induced immunosuppression and aggressive progression of primary cranial vault lymphoma presenting as a management challenge, a case report, and a literature review.

Background: We needs to study Primary Large cell Non-Hodgkin's Lymphoma of the cranial vault, which is rare, and its association with COVID19 has not been reported, which may have an immunosuppressive effect to aggravate its progression. Patient details: Our patient, a 53-year-old male, noticed fast growth of posterior cranial vault lesion from 2 to 10 cm size in last 6 months after COVID 19 affliction. MRI brain with contrast revealed lesions suggesting meningioma. The whole-body PET scan was normal. Following Subtotal excision of the mass, histopathology revealed large B-cell Non-Hodgkin's lymphoma (DLBCL). Immunohistochemistry showed positive results for CD10, CD20, CD45 (LCA), ALK, and BCL-VE with a Ki-67 index of 90-95%. Following radiotherapy and chemotherapy patient is disease-free on imaging and doing well at 5 months of follow-up. Conclusions: Early intervention with excisional biopsy and timely chemo and radiotherapy in favorable immunostaining may add survival benefits even in malignant features induced by immunosuppressing diseases such as COVID19 in diffuse large B-cell lymphoma (DLBCL) of the scalp.

Immunocytochemistry of the ocular surface after different techniques of limbal stem cell transplantation for chronic chemical burns.

AIM: To compare the immunocytochemistry (ICC) on impression cytology of corneal surface epithelium after simple limbal epithelial transplantation (SLET) and conjunctival-limbal autograft (CLAU). METHODS: A prospective study of 20 patients above 1 year of age with chronic chemical burns, who underwent limbal stem cell transplantation (LSCT). They were divided equally in group A (SLET) and group B (CLAU). ICC was done for cytokeratin 3 (CK3) and cytokeratin 19 (CK19), preoperatively and postoperatively at 6 months. RESULTS: Four cases were excluded due to inadequate cellularity in preoperative or postoperative samples. On ICC analysis, in the remaining 16 patients mean CK3 and CK19 positivity changed from 2.06%±1.73% and 83.56%±8.69% preoperatively to 70.62%±13.2% (p<0.0001) and 5.93%±4.17% (p<0.0001), respectively, at 6 months post LSCT. In group A (8 patients) mean CK3 and CK19 positivity of 2%±1.8% and 84.5%±8.4% preoperatively changed to 70%±13.8% (p<0.0001) and 6.25%±5.1% (p<0.0001) at 6 months respectively. While in group B (8 patients), it was 2.12%±1.7% and 82.62%±9.4% preoperatively and 71.25%±013.5% (p<0.0001) and 5.62%±3.2% (p<0.0001) at 6 months. There was no significant difference in expression of CK3 (p=0.084) and CK19 (p=0.744) post SLET or CLAU.Three patients with complete reversion had clear corneas at 6 months. CONCLUSION: Reversion of the epithelium to corneal phenotype was documented post LSCT with no difference in expression of CK3 between the two procedures (SLET/CLAU).

Comparative analysis of the risk factors influencing recovery of function from Oculomotor nerve Palsy in unruptured and ruptured Posterior Communicating Artery Aneurysms.

AIM: Few studies have analyzed and compared the risk factors responsible for the recovery of function from oculomotor nerve palsy (OMNP) between cases with unruptured and ruptured posterior communicating artery (PCOM) aneurysms. We also have assessed these risk factors and simultaneously compared the benefits of procedures (clipping vs. coiling) in the recovery of function from OMNP. MATERIAL AND METHODS: Among the 225 cases of aneurysm treated in our department between July 2018 and February 2020, 25 patients with PCOM aneurysm with OMNP (unruptured: n = 13; ruptured: n = 12) were retrospectively analysed . RESULTS: The average duration from onset of symptoms to treatment in unruptured PCOM aneurysm cases was 13.33 ± 3.76 days compared with 7.41 ± 2.42 days in ruptured aneurysm cases. Moreover, an 80% improvement was observed when OMNP was treated within 17 days with the earliest improvement noticed in 33.05 ± 18.75 days in unruptured aneurysm cases compared with 39.66 ± 31.75 days in ruptured PCOM aneurysm cases. Stepwise logistic regression analysis revealed that the type of aneurysm (better recovery in unruptured aneurysm cases) was a significant risk factor (p = 0.0126), but not the procedure (clipping vs. coiling) performed, for function recovery from OMNP. CONCLUSION: Patients with unruptured PCOM aneurysms with OMNP have a better recovery rate than those with ruptured PCOM aneurysms. No procedural (clipping vs. coiling) advantages were observed on the recovery of function from OMNP. Transmitted pulsation reduction significantly affects the recovery of function from OMNP.

Primary pituitary tuberculosis.

Tuberculosis is an infectious disease that involves any organ. However, the primary pituitary tuberculosis is an extremely rare disease. Intracranial tuberculomas account for 0.15-5% of intracranial space-occupying lesions, of which, pituitary as the primary site is unusual, and easily misdiagnosed as pituitary adenoma. In this setting, the late diagnosis can result in permanent endocrine dysfunction. We report the case of a 50-year-old woman who presented to the neurosurgery outpatient department with complaints of progressively increasing headache and diminished vision over the last year. On the clinical examination, the patient was conscious and oriented. The routine hematological and biochemical workup showed an increased erythrocyte sedimentation rate (ESR) and increased prolactin levels. The radiological working diagnosis was consistent with pituitary macroadenoma. No other radiological and/or clinical clue that could elicit the suspicion of pulmonary or extrapulmonary lesions of tuberculosis was found. The transsphenoidal endonasal tumor excision was done. The histopathology showed numerous epithelioid cell granulomas, Langhans giant cells along with scant necrosis. Ziehl Neelsen staining demonstrated acid-fast bacilli, and the final diagnosis of pituitary tuberculoma was made. We report this rare case of pituitary lesion that may be included in the differential diagnosis of sellar lesions to avoid unnecessary surgical interventions, especially in regions where the disease is endemic.

Analysis of Giant Intraventricular and Extraventricular Epidermoids, Defining Risk Factors for Recurrence, an Institutional Experience.

BACKGROUND: Multicompartmental intraventricular epidermoids behave differently from multicompartmental extraventricular lesions and localized lesions during its management. Few studies are available which have analyzed risk factors separately in these groups of cases for recurrence of these lesions and time to recur. MATERIALS AND METHODS: In this retrospective observational study, 72 cases of intracranial epidermoid were treated over a span of 7 years. Cases were categorized into three groups. Group 1 comprised 15% (11/72) of cases with intraventricular multicompartmental, Group 2 with 22% (16/72) extraventricular giant tumors with multicompartmental involvement and size >4.5 cm, and Group 3 comprised 63% (45/72) of patients with lesions <4.5 cm and localized. Data pertaining to demography, clinical and radiological features, surgery performed, postoperative complication, histology, and follow-up were obtained from medical records available in the institute. RESULTS: The average duration to treat was 1.86 ± 0.52 (standard deviation [SD]) years, with headache as a major complaint in all the groups. Combined endoscope-assisted microsurgery was performed in 38.8% (28/72), microsurgery in 54.1% (39/72), and endoscopic excision in 6.9% (5/72) of cases. Tumor calcification was found in 23.6% (17/72) and preoperative capsular enhancement was seen in 19.4% (14/72) which persisted in 79% (11/14) of cases postoperatively on subsequent follow-up suggesting recurrence. On stepwise logistic regression analysis, preoperative capsular enhancement was a strong predictor of recurrence of tumor (P = 0.001). The average follow-up was 46 ± 14.92 (SD) months in Group 1, 52.34 ± 11.45 (SD) months in Group 2, and 63.36 ± 18.42 (SD) months in Group 3. CONCLUSION: Although the intracranial epidermoid is known to recur after long interval, tumor with specific characteristics can recur in short span of 5-6 years. Tumor characteristics such as preoperative capsular enhancement, multicompartmental distribution in vertebrobasilar territory, large size, and presence of calcification are strong predictors for recurrence. Performing endoscope-assisted microsurgery can decrease the postoperative morbidities but does not reduce the recurrence risk.