Prognostic Factors of the Primary Central Nervous System Lymphoma: Clinical Experience from a Tertiary Care Center in the Middle East.

Aim Primary central nervous system lymphoma (PCNSL) is a rare extra nodal non-Hodgkin's lymphoma. The optimal treatment for PCNSL is still unclear. In this study, we present our experience with management of PCNSL in a tertiary care center in Iran. Methods In this retrospective study, 58 patients with tissue diagnosis of PCNSL were studied. All patients were treated with chemotherapy including intravenous high-dose methotrexate, rituximab and temozolomide and radiotherapy by the same oncologist. Statistical analysis was performed using SPSS. Results The mean overall survival (OS) in this study was 37.4 ± 13.6 months and the mean progression free survival (PFS) was 35.1 ± 9.8 months. The mean time to progression was 15.2 ± 8.79 months among 8 patients who experienced progression in this series. Finding of a positive CSF cytology was not linked with disease progression, while HIV infection and multifocal involvement at initial presentation were strongly linked to a lower PFS. The single most important factor affecting the OS was the histopathologic type of the PCNSL; two of the three patients who died from their disease in this series had non-B cell PCNSL, whereas only one patient with DLBCL died because of brainstem involvement. Conclusion The results of this study show a lower rate of HIV-infection in patients with PCNSL as compared to the series from the western countries. Non-B cell histopathology and HIV-infection were found to be associated with the dismal prognosis.

Initial Experience with Diffusion-weighted Imaging to Predict the Tumor Consistency and Surgical Success in Solid Growth Hormone Producing Pituitary Macroadenomas.

BACKGROUND: Tumor consistency is an important factor impeding transsphenoidal resection of some pituitary macroadenomas. Preoperative prediction of the tumor consistency may help neurosurgeons in preparing the patients for other therapeutic options after a subtotally resected growth hormone (GH)-producing macroadenoma. We present the preliminary results of our study about the application of the preoperative diffusion-weighted (DW) magnetic resonance imaging (MRI) to predict the consistency and resection rate of GH-producing pituitary macroadenomas. MATERIALS AND METHODS: Sixteen primary patients with solid GH-producing pituitary macroadenomas were enrolled. Hormonal assays as well as standard and DW-MRI were obtained before surgery. All the patients were operated via an endoscopic transsphenoidal approach. The intraoperative tumor consistencies (suctionable versus nonsuctionable) were documented. The samples were stained for measurement of the collagen content (low, moderate, and high). Postoperative hormonal study and MRI were performed after 8 weeks to evaluate the resection ratio and the hormonal remission. RESULTS: On DW images, the tumor diffusion was enhanced (free) in four, moderate in ten, and restricted in two patients. The tumor was suctionable in 14 cases; gross total resection and hormonal remission were achieved in 12/14 of these. All the 14 suctionable tumors had moderate to enhanced diffusion on DW imaging (DWI). The two patients with a nonsuctionable fibrous tumor had a restricted diffusion in DWI. These were the only ones to have high collagen content in the histopathologic study. CONCLUSION: DWI could help identify the fibrous nonsuctionable GH-producing adenomas from the others.

Pituitary Apoplexy during Treatment of Prolactinoma with Cabergoline.

Pituitary apoplexy is a rare clinical presentation caused by infarction of the pituitary gland or adenoma with or without hemorrhage. Although pituitary apoplexy is usually spontaneous, one of the predisposing factors is treatment with dopamine agonists, especially bromocriptine. The occurrence of apoplexy during cabergoline therapy is reported much less frequently. In this article, we report a 34-year-old man with macroprolactinomas who developed sudden visual deterioration due to pituitary apoplexy 1 year after initiation of cabergoline therapy. He was treated via endoscopic trans-sphenoidal surgery and his visual status recovered dramatically.

'Coexisting pituitary adenoma and suprasellar meningioma-a coincidence or causation effect: report of two cases and review of the literature'.

Coexistence of pituitary adenoma (PA) and another type of brain tumor is a very rare clinical scenario. Even though such a presentation can be an incidental event but a thorough review of the literature will be made to elucidate the possible mechanisms and treatment options in similar cases. Two cases of concomitant sellar and suprasellar/diaphragmatic tumors are reported. A 37-year-old lady with prolactinoma and a suprasellar diaphragmatic meningioma and a 42-year-old acromegalic man with suprasellar/diaphragmatic meningioma and a PA. Both meningiomas were removed transcranially. The prolactinoma could be managed medically and the growth hormone secreting adenoma was removed trans-sphenoidally. The visual problems and hormonal imbalances of both patients improved postoperatively. The literature is reviewed on this topic and the possible pathogenesis and management protocol of similar lesions are discussed.

Masticatory ability with depression, anxiety, and stress: Does there exist any association?

BACKGROUND: Masticatory ability as a subjective response to masticatory function indicates patients' perception of their mastication. To the best of our knowledge, there has been no study on association between masticatory ability and psychological status. This study investigated the association between self-assessed masticatory ability (SAMA) and psychological status among a large sample of Iranian adults. MATERIALS AND METHODS: In this cross-sectional study, data were extracted from 4135 adults who had been completed information in 20 counties across Isfahan province regarding masticatory ability and psychological statuses (depression, anxiety, and stress). An SAMA questionnaire, the Hospital Anxiety and Depression Scale and General Health Questionnaire were used to measure masticatory ability, depression and anxiety, and stress of study population. To analyze the data, ANOVA, χ(2) test, and multinomial regression were applied at 0.05 for the significance level. RESULTS: Masticatory ability was significantly correlated with depression (P < 0.001), anxiety (P < 0.001), and stress (P < 0.001). The participants in high masticatory ability group reported lower scores for presence of these psychological variables. Furthermore, males reported significantly higher level for masticatory ability than females (P = 0.025). In addition, there were significant association between low and moderate masticatory ability with anxiety (1.09, 1.08), depression (1.15, 1.13), and stress (1.11, 1.09), respectively. The association was still significant after adjusting for age, sex, educational level, and marital status. CONCLUSION: Despite study limitations, the results of this study provide evidence that participants with higher score of depression, anxiety, and stress suffer lower masticatory ability.

Impact of electrolyte imbalances on the outcome of aneurysmal subarachnoid hemorrhage: A prospective study.

BACKGROUND: Electrolyte disturbances are frequently observed during the acute and subacute period after subarachnoid hemorrhage (SAH) and may potentially worsen therapeutic outcome. This study was conducted to determine the pattern of electrolyte disturbance in the acute and subacute phase after SAH and their effect on the long-term outcome of the patients. MATERIALS AND METHODS: Fifty-three patients were prospectively enrolled. The standards of care for all patients were uniformly performed. The serum levels of electrolytes (sodium, potassium and magnesium) were determined with measurements obtained on admission, 3-5 and 7-10 days after SAH. Radiographic intensity of hemorrhage (Fisher's scale), and the clinical grading (World Federation of Neurosurgical Societies grade) were documented in the first visit. The outcomes were evaluated using Glasgow outcome scale at 3 months after discharge. RESULTS: Hyponatremia was the most common electrolyte imbalance among the patients but did not worsen the outcome. Although less common, hypernatremia in the subacute phase was significantly associated with poor outcome. Both hypokalemia and hypomagnesemia were predictive of poor outcomes. CONCLUSIONS: Because electrolyte abnormalities can adversely affect the outcome, the serum levels of electrolytes should be closely monitored with serial measurements and treated properly in patients with aneurysmal SAH.

Relationship between subjective halitosis and psychological factors.

OBJECTIVES: Subjective halitosis is a growing concern in the fields of dentistry and psychology. This study was designed to determine the association between subjective halitosis and contributing psychological factors. METHODS: Data for this cross-sectional study were gathered from 4,763 participants who had answered questions on subjective halitosis and psychological factors (depression, anxiety, stress and personality traits) in the study on the epidemiology of psychological, alimentary health and nutrition (SEPAHAN). Binary logistic regression was used for data analysis. RESULT: The mean age of all subjects was 36.58 years; and the majority of subjects were female (55.8%), married (81.2%) and graduates (57.2%). The prevalence of subjective halitosis was 52.8%. The majority of subjects with the complaint of subjective halitosis were married (P<0.001) and young (P=0.07). Participants with subjective halitosis were significantly more anxious [odds ratio (OR)=1.76, 95% confidence interval (95% CI): 1.38-2.24], stressed (OR=1.41, 95% CI: 1.17-1.71) and depressed (OR=1.31, 95% CI: 1.09-1.57). Among personality traits, neuroticism was a risk factor (tertile 1 vs. tertile 2: OR=1.29, 95% CI: 1.09-1.51; and tertile 1 vs. tertile 3: OR=1.74, 95% CI: 1.43-2.13) and conscientiousness was revealed to be a protective factor (tertile 1 vs. tertile 2: OR=0.82, 95% CI: 0.70-0.98; and tertile 1 vs. tertile 3: OR=0.65, 95% CI: 0.53-0.80). CONCLUSION: It seems that psychological factors, such as anxiety, depression and stress, as well as some personality traits, can be considered as risk factors for subjective halitosis. Multidisciplinary efforts by dental and psychological professionals must be considered to address this problem.

Predictive value of diffusion-weighted MRI for tumor consistency and resection rate of nonfunctional pituitary macroadenomas.

BACKGROUNDS: Firm tumor consistency is one of the most important factors that impede sufficient removal of pituitary macroademoas via a transsphenoidal approach. The utility of diffusion-weighted (DW) magnetic resonance imaging (MRI) in predicting the tumor consistency and successfulness of transsphenoidal resection was evaluated in this study. METHODS: Thirty consecutive primary cases of nonfunctional pituitary macroadenomas were prospectively enrolled. Conventional and DW MRI were done for all the patients and the apparent diffusion coefficient (ADC) values and the signal intensity of the solid tumor were determined. Intraoperative report of tumor consistency, the degree of fibrosis and percentage of collagen content were documented. The 8 weeks postoperative MRI was used for calculation of the tumor resection rate. RESULTS: The tumor consistency was soft in 10 patients (33.3 %), intermediate in 14 patients (46.7 %) and hard in 6 patients (20 %). The mean collagen content percentage was 10, 23.5 and 66 % (p = 0.009) and the average resection rate was 75, 43 39 % in the three groups respectively (p = 0.001). The mean ADC value was not significantly correlated with the tumor consistency and resection rate. Tumors with isointense to hyperintense signal on DW MRI were more commonly removable by suction and had higher resection rates than those with hypointense signals (p = 0.019). For ADC values within the range of 600-740 × 10(-3) mm(2)/s, a residual volume larger than 20 % of the tumor was more likely. CONCLUSIONS: DW MRI was useful to predict the tumor consistency, collagen content and the chance of removal of pituitary macroadenomas through endoscopic transsphenoidal surgery, and is recommended in the preoperative patient evaluation.

Extracranial aneurysm of the distal PICA presenting as isolated fourth ventricular hemorrhage: case report and literature review.

BACKGROUND: Posterior inferior cerebellar artery (PICA) aneurysms are relatively uncommon, comprising only 0.5-3% of all intracranial aneurysms. Distal PICA aneurysms are much more uncommon, with more than 200 cases being reported in the literature. The finding of an extracranially located aneurysm of distal PICA is considered a true rarity. METHODS AND DISCUSSION: A rare case of extracranially located PICA aneurysm presenting with isolated fourth ventricular hemorrhage is presented and the diagnostic and therapeutic challenges discussed.