Extra-Axial Cerebello-Pontine Angle Medulloblastoma in an Infant: A Rare Case Report with Review of Literature.

Medulloblastoma is a fairly common neoplastic growth seen majorly in children, presenting as an intra-axial midline mass arising from the cerebellar vermis. However, its presentation as an extra-axial mass in the cerebellopontine angle (CPA) is extremely rare, such that, only 39 cases have been reported in the world literature till 2016. Only one case has ever been reported of an extra-axial CPA medulloblastoma in an infant; who was aged 1 year. We present a case report of an 8-month-old infant, with an extra-axial CPA medulloblastoma and discuss its management strategy.

Pituitary Prolactinoma with Amyloid Deposits: Surgery or Dopamine Agonists? Review of Previous Reports and New Recommendations for Management.

BACKGROUND: Pituitary adenomas, macro and micro, are a common occurrence in most neurosurgical centers. Prolactinomas are the most common pituitary tumors and are often treated nowadays with dopamine agonists such as cabergoline, with good results. AIMS AND OBJECTIVES: To suggest new therapeutic guidelines for treating Prolactinomas with Amyloid deposits on preoperative detection of Amyloid deposition in Pituitary tumors, based on MRI characteristics. MATERIALS AND METHODS: We report a case of a pituitary prolactinoma with amyloid deposits in a 45-year-old male who underwent a transsphenoidal excision of the adenoma. Although on magnetic resonance imaging scans, no amyloid was reported, at histopathology, spherical amyloid within the pituitary tumor was found in abundance. The patient underwent surgery without any trial of cabergoline due to rapid deterioration of vision. CONCLUSION: Prolactinomas with amyloid deposits are known not to respond to dopamine agonists (cabergoline) by a reduction in size and may ,in fact increase in volume. Therefore, we recommend that in prolactinomas not responding to medical therapy, deposition of amyloid has to be considered as a cause for failure of medical therapy and surgery and then has to be offered pronto.

Bespoke GelFoam Wafers: A Practical and Inexpensive Alternative to Oxycel for Hemostasis during Neurosurgery.

BACKGROUND: Since the beginning of neurosurgery, intraoperative parenchymal bleeding has been a major problem. Achievement of hemostasis is the endpoint of any cranial or spinal neurosurgical exercise and is mandatory to avoid postoperative hematomas which mar the ultimate outcome of the surgery. Several biosurgical agents are used to achieve this goal. Agents such as oxidized cellulose, gelatin foam, fibrillar collagen, fibrin sealants, and antifibrinolytic agents are used, each having a different mechanism of action. MATERIALS AND METHODS: The authors describe a simple technique for substituting oxidized regenerated cellulose (Surgicel) for lining the surgical cavities after excising brain lesions, with customized gelfoam wafers fashioned on the surgical trolley. This has been used in over 8000 cases with excellent hemostatic results over the last 25 years. No complications are noted with use of these wafers. RESULTS: In a randomized trial done by us, similar hemostatic effect was found between oxycel and the gelfoam wafers described by us with satisfactory outcomes of surgeries. No previous use of such custom-fashioned wafers has been described for neurosurgical hemostasis in the literature.

Spontaneous Intracranial Extradural Hematoma Secondary to Hypofibrinogenemia: A Rare Case Report.

Spontaneous extradural hematoma is a well-documented but fairly rare condition, which can be associated with conditions such as vascular malformations, sickle cell disease, metastasis to the skull, infectious diseases of the skull, coagulation disorders, and use of anticoagulants. Of these, very few cases are of life-threatening extradural hematomas in adults, where hypofibrinogenemia is the cause of bleed, without any history of trauma. In this report, we have discussed the management of such a patient.

Ischemic central retinal vein occlusion and neovascular glaucoma as a result of optic nerve head drusen.

PURPOSE: The purpose of this study was to report a case of ischemic central retinal vein occlusion (CRVO) caused by optic nerve head drusen. METHODS: Case report and review of the literature. RESULTS: A healthy 13-year-old boy was diagnosed with bilateral optic nerve head drusen. Two years later, he developed an ischemic CRVO and secondary neovascular glaucoma. A full medical workup was negative. Despite treatment, his vision eventually declined to no light perception from a funnel detachment. CONCLUSION: Nonischemic CRVO or venous stasis retinopathy is a well-known entity associated with optic nerve head drusen. The authors report a case of ischemic CRVO in a patient with no underlying risks for this other than the observed drusen. This report clearly shows that optic nerve drusen may not be entirely benign and that they can precipitate ischemic CRVO.

Clinical course and management of postoperative methicillin-resistant Staphylococcus aureus keratitis in immunocompromised patients: two case reports.

We describe the clinical course and successful treatment of two cases of methicillin-resistant Staphylococcus aureus (MRSA) keratitis. In case 1, MRSA keratitis occurred 5 days after cataract extraction, associated with endophthalmitis; in case 2, diagnosis was made 19 months after penetrating keratoplasty. Treatment in both cases consisted of topical fortified vancomycin and fortified bacitracin. A third topical antibiotic, polymyxin B-trimethoprim, was added to the therapeutic regimen in case 2, one month into the treatment. Oral doxycycline was prescribed to reduce collagenase activity and treat blepharitis. Mupirocin nasal ointment and skin antiseptics were used to decrease and eliminate potential MRSA colonization. Topical prednisolone acetate 1% was applied conservatively to mitigate inflammation in both cases. In case 2, topical cyclosporine A was also used for similar purposes. Keratitis may have worsened while on these immune-modulating drops, especially in case 2, and eradication of infection may have been slowed. Eventually both patients achieved full resolution of infection. Duration of keratitis was 3 and 1.5 months, respectively. Polyantimicrobial therapy is effective in eradicating MRSA-related postoperative keratitis. Topical fortified vancomycin and fortified bacitracin were used in both cases, with a third topical antibiotic, polymyxin B-trimethoprim, also required in case 2. Oral doxycycline, nasal mupirocin, and antiseptic soap may be useful adjuncts in management. Treatment time to achieve full resolution may be prolonged relative to other types of bacterial keratitis. Alterations in immune status may have lengthened the time of treatment. Our two patients were immune compromised and were also susceptible to endophthalmitis. It is possible that topical immune-modulating drops such as prednisolone acetate may potentiate MRSA infection, and if used, should be only done so with great caution.

Comparison of second-generation hand-assisted laparoscopic devices for surgeon pain and arm circulation.

OBJECTIVES: To compare two second-generation hand-assist devices (HADs) for surgeon pain and manual blood flow over time in an in vitro model. METHODS: Nineteen participants placed their nondominant hand through both the LapDisc and GelPort into a pneumoperitoneum chamber with an insufflation pressure of 15 mm Hg for a 2-hour test period. Pain, on a 10-point visual analog scale, and manual blood flow to the index finger using a laser Doppler skin probe were measured at 10 points during the 2 hours. Participants completed a questionnaire regarding hand comfort and the physical effects of the HAD. RESULTS: At 30, 45, and 60 minutes after hand insertion, the pain scores were significantly greater for the GelPort than for the LapDisc (P = 0.04, P = 0.01, and P = 0.03, respectively). The GelPort caused an immediate reduction in manual blood flow, and the LapDisc caused a small initial increase in manual blood flow (P = 0.03) and, thereafter, a decrease in blood flow. Three participants voluntarily removed their hand at 30, 45, and 60 minutes owing to the pain from GelPort use. No participant withdrew from the LapDisc because of pain. CONCLUSIONS: Both HADs resulted in surgeon discomfort in our in vitro model. The GelPort resulted in more subjective pain compared with the LapDisc. Both HADs caused a reduction in manual blood flow. However, compared with the LapDisc, the GelPort caused significantly more reduction in manual blood flow. Surgeon comfort is only one parameter to consider when choosing a HAD.