Functional outcomes in intradural extramedullary spinal tumors.

Background: Intradural extramedullary (IDEM) spinal cord tumors account for approximately two-thirds of benign intraspinal neoplasms. These are amenable to gross total excision but can have variable functional outcomes, which plays a key role in assessing their impact on a patient's quality of life. Understanding the functional outcomes associated with these tumors is crucial for healthcare professionals to devise appropriate treatment plans and provide comprehensive care. Methods: In this study, we retrospectively reviewed the outcomes of 130 patients with IDEM tumors who underwent surgery in the past six years between January 2017 and December 2022 at a single institution. Patient demographics, symptoms, and tumor characteristics (anatomical and pathological) in all operated spinal IDEM tumors were analyzed. The neurological findings obtained during the preoperative stage and the postoperative follow-up were evaluated according to the Frankel grading. The back pain was assessed using the Denis pain scale (DPS). Results: The age range, gender distribution, presentation, histopathology, and tumor characteristics were analyzed. The histopathological outcomes of the study were as follows: 56 cases of schwannoma, 37 cases of meningiomas, 16 patients of neurofibroma, six cases of epidermoid cyst, five cases each of ependymoma and dermoid cyst, three cases of arachnoid cyst, two cases of metastasis, and one case of paraganglioma. Pain was the most common symptom (38.5%), followed by weakness in limbs (31.5%), paresthesia/numbness (22.3%), and sphincter disturbance (7.7%). Complete total resection was seen in 93% of cases, with 7% undergoing subtotal excision. The complications encountered were - four cases of surgical site infection and one case each of cerebrospinal fluid leak, pseudomeningocele, and epidural hematoma. In our series, 49.3% of patients had significantly good improvement in functional outcomes as per improvement in Frankel score, and 43% of patients had good functional improvement. Significant functional improvement was noted at immediate postoperative follow-up, 2-week follow-up, and six-month follow-up periods. Reoccurrence was seen in 7 cases (5.4%). The DPS score mean values showed a significant decrease over the follow-up duration as compared to preoperative mean values. Significantly poor outcome was seen in IDEM tumours present anteriorly. Conclusion: The IDEM tumors are usually benign and are readily detected by contrast-enhanced magnetic resonance imaging scans. These have variable functional outcomes in different centers. Assessing this functional outcome is an essential aspect of managing IDEM spinal tumors. It was observed through our study that the ventral location of the tumor, thoracic tumors, and poor preoperative neurological status of the patient correspond with poorer postoperative functional outcomes. Furthermore, a significant decrease in the pain symptoms with improvement of Frankel score was seen postoperatively, thus this being suggestive of a significant improvement of functional outcome after surgery. This study helps to conclude that the morbidity associated with the resection of IDEM tumors is not as significant as originally thought to be.

Lateral sacral artery aneurysm.

A rare case of aneurysm of the lateral sacral artery is reported. This 46-year-old female presented with complaints of bowel and bladder incontinence and decreased perianal sensation for the past 15 months. She underwent laminectomy and diskectomy for the diagnosis of a prolapsed disk at peripheral hospital where the surgeon was confronted with a severe and unexpected hemorrhage, and surgery was aborted without effective treatment. Prior medical history includes hypertensive kidney disease with a renal transplant eight years ago. Magnetic resonance imaging and angiographic findings were suggestive of a lateral sacral artery aneurysm. Patient with a history of renal transplant and presenting with cauda equina require a more thorough assessment, and a differential of lateral sacral artery aneurysm should always be kept in mind. Our purpose is to report the pre-operative features of the lateral sacral artery aneurysm and its treatment modalities.

PSMA Avidity in the Heterotropic Ossification-An Incidental Finding on PSMA PET/CT.

ABSTRACT: The upregulations of prostate-specific membrane antigen (PSMA) antigen are used for the presence of prostate cancer. However, published literature shows incidentally detected PSMA uptake in various nonprostatic benign and malignant conditions, which led to questioning the specificity of PSMA-targeted PET. In present case, we highlighted the abnormal PSMA expression in the benign bone abnormality.

Craniovertebral Junction Anomalies: An Overlooked Cause of 'Posterior Circulation Stroke'.

Background: Vertebral artery dissection (VAD) is a treatable cause of vertebrobasilar ischemic stroke and can be spontaneous or more commonly traumatic. Craniovertebral junction (CVJ) anomalies are a rare and often overlooked cause of VAD. Objective: The objective of this study was to study cases where CVJ anomaly presented as posterior circulation infarct and to conduct a relevant literature review. Materials and Methods: The medical records of seven patients who were managed for posterior circulation infarct associated with CVJ anomaly at our center from January 2009 through August 2013 were reviewed. PubMed and MEDLINE databases were also searched for similar cases, and the published case reports/series were reviewed. Results: Seven patients met our inclusion criteria and were included in the study. The mean age was 17.4 years (range: 10-35 years). All the patients were males. The most common symptoms were headache, vomiting, and gait ataxia. Slurring of speech was seen in one patient. One patient had repeated episodes of gait ataxia with left-sided weakness with complete recovery in between the episodes. One patient presented in unconscious state. Four patients complained of vertigo. The median duration of symptoms was 7 days (range: 3 days-12 months). Conclusions: CVJ anomalies can present as posterior circulation infarct. One must evaluate all patients with posterior circulation stroke, especially young patients, for possible CVJ anomalies. Dynamic lateral cervical spine X-ray is an important tool to diagnose AAD. CVJ anomalies represent a treatable cause of VAD.

A Prospective, Randomized, Interventional Study of Oral Iron Supplementation Comparing Daily Dose with Alternate Day Regimen Using Hepcidin as a Biomarker in Iron Deficiency Anemia.

AIM: To assess effect of daily vis-a-vis alternate day oral iron therapy in terms of hemoglobin, reticulocyte hemoglobin equivalent (RET-He) and GI side effects using hepcidin as a biomarker. METHODS: A hospital based randomized interventional two-arm analytical study was done among patients of IDA (20 in each group). The study population was divided into two groups by randomisation. Group 1 received oral iron supplements on alternate day and Group 2 received iron supplements daily. Hemoglobin, RET-He, Serum ferritin and Hepcidin level were assessed. RESULTS: On day 2nd, the rise in Hepcidin was not significant from base line in alternate day therapy group but was significantly increased in daily therapy group. On day 3, the rise in hepcidin was significant from base line in both the groups but the mean change in hepcidin was more in daily therapy group. RET-He began increasing on day 2nd in both the groups. In alternate day therapy group, the rise in RET-He was significant from base line from the day 2nd onwards while the rise in RET-He in daily therapy group was not significant even on day 3. In alternate day iron therapy group, the mean increase in hemoglobin on day 21th (1.58 ±0.53 gm/dl) was significantly more than mean increase among daily therapy (0.41 ± 0.25 gm/dl, P <0.05). CONCLUSION: Alternate day single tablet dosing schedule of oral iron therapy (60mg of elemental iron, ferrous sulfate) was more effective and better tolerated (gastrointestinal side effects) compared to daily supplementation in IDA.

Low Dose Prophylaxis vis-a-vis on-Demand Treatment Strategies for Hemophilia: A Cost Effective and Disability Attenuating Approach.

AIM: To assess effect of low dose prophylaxis in hemophilics in terms of bleeding, joint function, QoL and cost-effectiveness. METHODS: Analytic study done during one year among 70 adult hemophilics. In observation period (12 weeks), on-demand factor and during prophylaxis (12 weeks), low dose factor was given (Factor VIII 10 IU/KgBW biweekly for haemophilia A and Factor IX 20 IU/KgBW weekly for haemophilia B). Clinical joint assessment was done by Gilbert score and improvement by WFH definitions. RESULTS: Bleed reduced by 68.99% in moderate hemophilics (40 v/s 129) and 64.86% in severe hemophilics (26 v/s74) (p<0.05). During observation in moderate hemophilics, joint, soft tissue and mucosal bleeds occurred in frequency of 120, 1 and 8. This was reduced to 39 joint bleeds, 1 soft tissue bleed and no mucosal bleed during prophylaxis. In severe hemophilics, 70 joint, 2 soft tissue bleeds and 2 mucosal bleeds occurred during observation which reduced to 26 joint bleeds without soft tissue/mucosal bleed in prophylaxis. Bleeding episodes decreased by 65.79% in joints, 66.67% in soft tissues, 100% mucosal bleeds. After prophylaxis one joints (0.61 %) showed good improvement in joint function, thirty (18.18 %) joints showed moderate improvement and ninety two joints (55.76 %) showed mild improvement in joint function. Hospitalization reduced by 60.34% (163 v/s 411) and absenteeism by 53.73% (279 v/s 603). Factors consumption reduced by 12.33 % during prophylaxis period. CONCLUSION: The low dose prophylaxis strategy significantly decreased the subsequent episodes of total bleeds including joint bleeds and improved the joint function as well as quality of life.

Management and Outcome Analysis of Conus and Filum ependymoma: A Tertiary Center Study.

BACKGROUND: Spinal ependymomas constitute approximately 2%-8% of primary adult central nervous system tumors. Authors analyzed demographic, clinical, radiological, surgical, and histopathological factors which correlated with the postoperative neurological outcome of patients who underwent surgery for conus and filum ependymoma (CFE). MATERIALS AND METHODS: A retrospective analysis of 31 patients regarding clinical feature, imaging study, surgical management, and McCormick grading system for assessing functional neurological status was carried out, who underwent surgical management for CFE between January 2009 and April 2014. Final neurological outcome at follow-up period was correlated with various factors in search to find out probable prognostic factors affecting final neurological outcome following surgical management. RESULTS: The myxopapillary ependymoma was observed in 55% of cases (n = 17), while 39% cases (n = 12) had Grade II ependymoma and rest 6% (n = 2) cases had anaplastic ependymomas. The mean age was 30 years (range 7-60 years) with male to female ratio of 1:0.82. Patients predominantly presented with pain (80.65%); mean duration of symptoms was 28.61 months. Only, the preoperative McCormick grade was found to be the statistically significant prognostic factor (P = 0.045), affecting neurological outcome however, the age, sex, duration of symptoms, location of the tumor, extent of the tumor, extradural spread, degree of surgical excision, vascularity of tumor, and histopathological World Health Organization grades were not found to be significant prognostic factors in the current study. CONCLUSION: The preoperative McCormick score was found to be the only statistically significant factor predicting the functional and neurological outcome after surgery, so surgical treatment should be offered early in the course of the disease to provide chance of preservation and good neurological recovery.

Spinal Cerebrospinal Fluid Drainage for prevention of Vasospasm in Aneurysmal Subarachnoid Hemorrhage: A Prospective, Randomized controlled study.

INTRODUCTION: Cerebral vasospasm following aneurysmal subarachnoid hemorrhage (SAH) is a major cause of mortality and morbidity. Despite various treatment modalities, the optimal management of vasospasm remains elusive. In this regard; we undertook a prospective, randomized controlled study to evaluate the effectiveness of lumbar cerebrospinal fluid drainage (LCSFD) for prevention of cerebral vasospasm and its sequelae. MATERIALS AND METHODS: Patients with aneurysmal SAH who met the inclusion criteria were randomized into two groups - Group I (30 patients) underwent LCSFD whereas Group II (30 patients) did not undergo LCSFD. All patients underwent aneurysmal clipping. Both the groups received standard neurosurgical treatment except for LCSFD. The outcome was measured in terms of (1) clinically evident vasospasm; (2) vasospasm-related cerebral infarction; (3) condition of the patient at the time of discharge; and (4) Glasgow outcome score (GOS) at 1- and 3-month follow-up. RESULTS: LCSFD conferred a statistically significant benefit reducing the incidence of clinical vasospasm from 63% (in non-LCSFD group) to 30% (in LCSFD group) (P = 0.01) and incidence of vasospasm-related cerebral infarction from 53% (in non-LCSFD group) to 20% (in LCSFD group) (P = 0.007). Incidence of vasospasm was quantitatively lower in LCSFD group across all Hunt and Hess grades; however, it was statistically significant in SAH Grade III (P = 0.008). Mean duration of hospital stay was slightly lower in LCSFD group compared to non-LCSFD group; however, it did not reach statistical significance. A higher incidence of meningitis in LCSFD group was not statistically significant. A higher GOS was observed in LCSFD group at 1- and 3-month follow-up as compared to non-LCSFD group. CONCLUSION: Drainage of CSF through a lumbar drain following aneurysmal SAH caused a statistically significant reduction in the incidence of clinical and radiological vasospasm and its sequelae. It also shortens the overall duration of hospital stay and improves the outcome as evidenced by a better GOS score at 1- and 3-month follow-up. The results of this prospective, randomized study establish the efficacy of LCSFD in prevention of vasospasm following aneurysmal SAH.

Traumatic Posterior Fossa Extradural Hematoma: Experience at Level I Trauma Center.

INTRODUCTION: Posterior fossa extradural hematoma (PFEDH) is rare among the traumatic brain injury and represent about 4-7% cases of all EDHs. This rare condition is rapidly fatal unless identified and intervened timely. Because of limited space in posterior fossa, comparatively small volume can cause clinical deterioration. Early diagnosis by cranial computed tomography and emergent evacuation is vital for a good outcome. MATERIALS AND METHODS: This study was conducted at Level I trauma center at All India Institute of Medical Sciences, New Delhi, India. Hospital medical records were reviewed from September 2007 to June 2015. There were 856 cases of acute EDHs and of these 69 cases had PFEDHs. Records of patients with PFEDHs were reviewed for the mode of injury, Glasgow Coma Scale (GCS) at admission, imaging, type of intervention, outcome, and follow-up. GCS was assessed at 6 months and 12 months follow-up. Pertinent literature is reviewed. RESULTS: Of these 69 patients, 51 were males and 18 females. The mean age of patients was 28.6 years (range 4-43 years). Forty-three patients had GCS 15 at admission, and only 4 of them had admission GCS <8. Mean EDH volume was 29.2 ml. Sixty-six patients were operated, three managed conservatively. Sixty-seven patients were discharged, of which, 56 (81.1%) had GCS 15. Two patients died. Most common associated injuries were long bone fractures (18, 26.1%) followed by blunt injury thorax (11, 15.9%). Mean follow-up duration was 69.2 months (range 6-94 months). At 6 months follow-up, 61 (88.4%) patients had good recovery (Glasgow Outcome Score [GOS] 5) and at 12 months, 62 (89.8%) had GOS 5. CONCLUSION: PFEDH are rare. They are usually associated with occipital bone fractures and may also have a supratentorial hematoma. It may be rapidly fatal due to the expansion of hematoma and compromise of the posterior cranial fossa space leading to brainstem compression, tonsillar herniation, and/or obstructive hydrocephalus. Early diagnosis and emergent evacuation lead to good outcome.

Ruptured Distal Middle Cerebral Artery Mycotic Aneurysm: A Rare, First Presentation of Infective Endocarditis.

Mycotic cerebral aneurysms are rare inflammatory aneurysms associated with high mortality and morbidity reaching up to 80% after rupture. We report a case of incidentally diagnosed infective endocarditis presenting with rupture of distal middle cerebral artery mycotic aneurysm and intracerebral hematoma. Aneurysmectomy with clip ligation of the terminal cortical branch and hematoma evacuation was done with good surgical outcome.

Primary Giant Sphenotemporal Intradiploic Meningioma.

Intradiploic meningioma is a rare subset of meningioma accounting for 1% of all cases. Authors report a rare case of giant sphenotemporal intradiploic meningioma with orbital extension in a 27-year-old female. It was managed successfully with complete surgical excision and bony reconstruction using autologous split thickness bone graft.

A randomized placebo-controlled trial of progesterone with or without hypothermia in patients with acute severe traumatic brain injury.

OBJECTIVE: Among newer neuroprotectant modalities, hypothermia and progesterone have shown a beneficial role in preliminary studies enrolling patients with severe traumatic brain injury (sTBI). The primary objective of this study was to evaluate the efficacy of progesterone with or without prophylactic hypothermia in acute sTBI patients. MATERIALS AND METHODS: This is a prospective, outcome assessor, statistician blinded, randomized, and placebo-controlled phase II trial of progesterone with or without hypothermia (factorial design). All adult patients (18-65 years) with acute sTBI (Glasgow coma score of 4-8) and presenting to trauma center within 8 h after injury were included in the trial. Computer-generated randomization was done after exclusion; sequentially numbered, opaque, sealed envelope technique was used for allocation concealment. The enrollment duration was from January 2012 to October 2014. The primary endpoint was dichotomized Glasgow outcome score (GOS) [poor recovery = GOS 1-3; good recovery = GOS 4-5], and secondary endpoints were functional independence measure (FIM) score and mortality rate at 6 and 12 months follow-up after recruitment. RESULTS: A total of 107 patients were randomized into four groups (placebo [n = 27], progesterone [n = 26], hypothermia alone [n = 27], and progesterone + hypothermia [n = 27]). The study groups were comparable in baseline parameters except for a higher incidence of decompressive craniectomy in the placebo group (P = 0.001). The analysis of GOS at 6 months revealed statistically significant better outcome in the hypothermia group (82%; P = 0.01) and a weaker evidence for progesterone group (74%; P = 0.07) as compared with the placebo group (44%). However, the outcome benefit was marginal at 1-year follow-up for the hypothermia group (82% vs. 58%, P = 0.17). The adjusted odds ratio of poor recovery at 6 months in the hypothermia group was 0.21 (confidence interval = 0.05-0.84, P = 0.03), as compared with the placebo group. Although mean FIM scores at 6 and 12 months respectively were marginally higher in the hypothermia and progesterone groups compared with the placebo group (P = 0.06 and 0.27), the proportion of functionally independent individuals were similar in all the groups (P = 0.79 and 0.51). The mortality rates were similar in all the groups at 6 and 12 months (P = 0.78 and 0.52 respectively). CONCLUSIONS: A strong evidence for prophylactic hypothermia and a weak evidence for progesterone therapy was observed for a better primary outcome at 6 months as compared to the placebo. A similar trend was observed at a 1-year follow-up. Contrary to our hypothesis, prophylactic hypothermia therapy suppressed the beneficial effects of progesterone therapy in sTBI patients. The complex cascades of factors responsible for such interactions are still unknown and need to be further determined.

Outcome Predictors in Pediatric Head Trauma: A Study of Clinicoradiological Factors.

INTRODUCTION: Traumatic injuries are the leading cause of death and a major cause of disability among children. About 70%-80% of the accidental deaths in pediatric age group result directly from central nervous system lesions. METHODS: The purpose of our study was to study all the patients of ≤18 years of age with head or spinal injury admitted in neurointensive care unit at our center, an apex trauma center in a developing country, between June 2009 and September 2011. We retrospectively analyzed various factors including type of injury, mode of injury, admission Glasgow coma score (in case of head injury), and mortality rate. OBSERVATIONS: The study population consisted of 264 injured children. Mean age was 8.3 ± 5.6 years (range 5 months to 18 years). Forty percent of patients were within 1-5-year age group. Head injury accounted for 89% of cases and 11% of cases were spinal injury patients. Low-velocity trauma was the most common mode of injury, accounting for 74% of the cases. The percentage of patients with mild, moderate, and severe head injury were 38%, 15%, and 47%, respectively, in the head injury group. Mortality in head injury patients was 18% and in spinal injury patients was 9%. Operative intervention was done in 56% of patients. Predictors of mortality included severe head injury, hospital stay <7 days, pneumothorax, the presence of hypotension, and deranged coagulation parameters. CONCLUSIONS: Head injury is much more common than spinal injury in pediatric patients and fall from height being the most common mode of injury. Severe head injury, hospital stay <7 days, pneumothorax, presence of hypotension, and deranged coagulation parameters are predictors of poor outcome.

Study of ß-catenin and BRAF alterations in adamantinomatous and papillary craniopharyngiomas: mutation analysis with immunohistochemical correlation in 54 cases.

Craniopharyngiomas (CP) are rare benign epithelial tumors, with two histological variants, namely the adamantinomatous variant (ACP) and the rarer papillary variant (PCP). They are locally infiltrative and surgically challenging tumors with severe long term morbidity. CTNNB1 mutations with ß-catenin immunopositivity and BRAFV600E mutations with anti-VE immunopositivity have been recently described in ACPs and PCPs respectively. We aimed to study BRAF and CTNNB1 gene mutations in CPs operated at our institute, and correlate it with clinicopathological parameters including histopathology and immunohistochemistry (IHC) for proteins VE-1 and ß-catenin. A total of 54 CPs diagnosed over 3-year duration were included. IHC for ß-catenin and VE-1 proteins, and Sanger sequencing for CTNNB1 (exon 3) and BRAF (exon 15) genes were performed. CTNNB1 mutations were identified in 63% (27/43) of ACPs while nuclear immunopositivity for ß-catenin was observed in 79% (34/43) of them. Seven ACPs showed ß-catenin immunopositivity in the absence of mutations. BRAFV600E (p.Val600Glu) mutations were observed in 57% of PCPs (4/7), while cytoplasmic immunopositivity for anti-VE1 antibody was observed only in 43% of PCPs (3/7), all of which also harboured BRAFV600E mutations. The mutations and IHC staining patterns of ACPs and PCPs were non-overlapping. Four cases with uncertain histological pattern could be subcategorised into specific variants only following mutation analysis/IHC. The identification of hallmark molecular signatures in the two CP variants holds promise for alternate improved treatment modalities, emphasizing the need for sub-categorization in routine histopathology reporting. IHC for ß-catenin and targeted sequencing for BRAFV600E serve as useful adjuncts.

Spinal arachnoid cysts - our experience and review of literature.

OBJECTIVE: Arachnoid cysts are discrete pockets of CSF or CSF-like fluid found adjacent to normal CSF spaces, either spinal or cranial. Spinal arachnoid cysts (SAC) are most commonly extradural, however intradural or perineural are also described. METHODS: All patients admitted to our center and surgically treated with a diagnosis of SAC, were included in the study. The results were analyzed in terms of the clinical symptoms, location of cyst, surgical procedure performed and outcome following surgery. RESULTS: Eleven patients were operated for SAC during the study period and the mean age at surgery was 32.9 ± 20.8 years. Male to female ratio was 2.7:1 in our series. Common presenting complaints were lower limb weakness and pain. The median duration of symptoms before surgery was nine months (mean 21 ± 28 months). Ten patients had extradural cysts while one had intradural cyst. Extradural cysts were managed by laminoplasty and excision of the cyst, except for one patient in whom the SAC extended from C3 to L2 and marsupialization of the cyst was done. The only patient with intradural cyst underwent cyst fenestration. One patient had two communications and both were closed. In our series, at the time of last follow up two patients became completely free of symptoms, while other five reported substantial improvement in their symptoms. Operative complications were noted in two patients. CONCLUSION: Formation and expansion of SAC is not completely understood. Myelography, CT myelography and cinematic MRI can demonstrate the location of the communication site between the spinal subarachnoid space and the cyst cavity. The usual management of SAC is excision of the cyst with closure of the dural defect in extradural cysts, while in case of intradural cysts, especially the ones located anterior to the cord, fenestration of the cyst is usually performed.

Genome-wide ChIP-seq analysis of EZH2-mediated H3K27me3 target gene profile highlights differences between low- and high-grade astrocytic tumors.

Enhancer of zeste homolog-2(EZH2) is a key epigenetic regulator that functions as oncogene and also known for inducing altered trimethylation of histone at lysine-27 (H3K27me3) mark in various tumors. However, H3K27me3 targets and their precise relationship with gene expression are largely unknown in astrocytic tumors. In this study, we checked EZH2 messenger RNA and protein expression in 90 astrocytic tumors of different grades using quantitative PCR and immunohistochemistry, respectively. Further, genome-wide ChIP-seq analysis for H3K27me3 modification was also performed on 11 glioblastomas (GBMs) and 2 diffuse astrocytoma (DA) samples. Our results showed EZH2 to be highly overexpressed in astrocytic tumors with a significant positive correlation with grade. Interestingly, ChIP-seq mapping revealed distinct differences in genes and pathways targeted by these H3K27me3 modifications between GBM versus DA. Neuroactive ligand receptor pathway was found most enriched in GBM (P = 9.4 × 10-25), whereas DA were found to be enriched in metabolic pathways. Also, GBM showed a higher enrichment of H3K27me3 targets reported in embryonic stem cells and glioma stem cells as compared with DAs. Our results show majority of these H3K27me3 target genes were downregulated, not only due to H3K27me3 modification but also due to concomitant DNA methylation. Further, H3K27me3 modification-associated gene silencing was not restricted to promoter but also present in gene body and transcription start site regions. To the best of our knowledge, this is the first high-resolution genome-wide mapping of H3K27me3 modification in adult astrocytic primary tissue samples of human, highlighting the differences between grades. Interestingly, we identified SLC25A23 as important target of H3K27me3 modification, which was downregulated in GBM and its low expression was associated with poor prognosis in GBMs.

Pediatric intraventricular meningioma: A series of six cases.

OBJECTIVE: Meningiomas in children is a rare occurrence. Primary intraventricular meningiomas (IVMs) are even rarer with reported incidence of 0.5%-5% of all meningiomas. The aim of the study was to describe the demographic profile, location, surgical approach, complications, and histopathology of six pediatric patients with IVM. MATERIALS AND METHODS: We retrospectively analyzed all intraventricular tumors operated at our Institute from January 2010 till July 2015. Patients' clinical details and follow-up were obtained from hospital records and scans were obtained from picture archiving and communication system. RESULTS: We found 6 pediatric patients (age ≤18 years) with histopathologically proven IVM. The mean age in this series was 14.6 years. Tumor was most commonly approached through the superior parietal lobule in this series. Gross total excision was achieved in all patients. The blood loss in the series was in the range of 600-2000 ml with a mean of 1100 ml. All were grade 1 meningioma on histopathological examination. Transitional meningioma was the most common histological subtype. None of the patients had a recurrence at last follow-up. CONCLUSIONS: Pediatric IVMs are rare tumors. They tend to have a male preponderance in contrast to adults which have a preference for females. Parietooccipital transcortical, transcallosal approach, middle/inferior temporal gyrus approach are the described techniques to tackle such tumors depending on the location of such tumors. Surgeons should watch out for massive blood loss during surgery, especially via the parietooccipital transcortical approach.

A rare case of white pearls in brainstem.

Intrinsic brainstem epidermoid is extremely rare, and only 14 cases have been reported. Authors report a classic case of brainstem epidermoid in a 14-year-old male child presenting with symptoms of brainstem involvement. The child underwent a successful surgical excision. The lesion was intrinsic and caused diagnostic dilemma based on conventional radiological images. Based on our experience in this case and a thorough review of literature, we are of the opinion that diffusion-weighted images are very important in establishing the diagnosis. Such lesions are challenging and attempt to remove adherent tumor capsule may produce additional neurological deficits.

A case of primary spinal atypical teratoid/rhabdoid tumor in a 5-year-old child.

Atypical teratoid/rhabdoid tumor (AT/RT) is a rare central nervous system neoplasm affecting children, and isolated primary spinal involvement is extremely rare. Authors describe a case of spinal AT/RT in a 5-year-old male child presenting with rapidly progressing quadriparesis diagnosed and managed surgically and medically. Biopsy revealed large, rhabdoid cells with prominent nucleoli in nest and immunohistochemistry further showed loss of integrase integrator 1 expression considered to be gold standard for diagnosis. AT/RT has extremely poor prognosis with median survival being 6 months.