Aneurysmal subarachnoid hemorrhage in a patient with dual autoimmune disorders. Perioperative challenges and management.

Autoimmune disorders (AIDs) are known to be associated with intracranial aneurysms; however, the coexistence of dual AIDs is a rare entity. Perioperative neuroanesthetic management of aneurysmal subarachnoid hemorrhage (aSAH) is typically complicated and challenging in such patients. In this report, we describe the successful management of a case of aSAH complicated by coexistent multiple sclerosis and systemic lupus erythematosus. A multidisciplinary team approach is warranted to manage such complicated cases.

Predictors of Outcome Following Interventions for Ruptured Intracranial Aneurysms in an Emerging Health Institution in West Bengal: A 6-Year Experience.

BACKGROUND: Microsurgical clipping and endovascular coiling have remained over the past half-century, the main options for definitive treatment of ruptured intracranial aneurysms. However, recent advances in endovascular techniques have broadened their application stimulating much debate regarding the usefulness of microsurgical options. For locations with limited capacity or evolving endovascular service, however, microsurgical treatment offers not only cost-effective and durable options but also oftentimes the only option available for most patients. MATERIALS AND METHODS: This was a single institution questionnaire-based retrospective study from West Bengal India. It was performed on patients with aneurysmal rupture managed from June 2010 to October 2016. Data analysis was performed with SPSS for Windows, version 21. RESULTS: One hundred and ten patients were studied. The mean age was 50.8 years (standard deviation [SD] ±13.5) for females and 50.2 (SD ± 12.4) for males (P = 0.8112, t-test). Ninety (81.8%) patients received microsurgical clipping. Microsurgical options such as wrapping, bypass, and excision were performed for 9 (8.2%) patients. Coiling was performed for 11 (10%) patients. ACOM was the most common site for ruptured aneurysm. Ictus-intervention interval (χ2 = 10.034, P = 0.007) and multiple surgical procedures (χ2 = 8.9341, P = 0.003) were the significant outcome determinants. Overall, 72.7% of those treated had a good outcome (Glasgow Outcome Score of 4 and 5). The good outcome was higher among microsurgery groups (73.7%) compared to the coiling group (63.6%) but this difference did not achieve statistical significance (χ2 = 0.46 P = 0.4976). CONCLUSION: Microsurgical options achieved good outcomes in the management of ruptured aneurysms in our series. Their availability makes them first-line options for low-income settings.

Posterior Fossa Hematoma Following Minor Trauma in an Infant with Rare Combined Factor V and Factor X Deficiency.

Congenital combined deficiency of factor V and factor X deficiency is extremely rare. We report this for the first time in literature in an infant who developed acute subdural hematoma in posterior fossa leading to hydrocephalus.

Takotsubo Cardiomyopathy Secondary to Ruptured Supraclinoid Internal Carotid Artery Aneurysm.

A 41-year-old lady who presented with sudden-onset severe headache diagnosed to have ruptured supraclinoid internal carotid artery (ICA) aneurysm. Her cardiac echocardiography showed features of Takotsubo cardiomyopathy. After stabilizing her cardiac condition, she underwent craniotomy and clipping of aneurysm. Both cardiac and neurological catastrophes were managed by the joint team with excellent outcome. This paper emphasizes the need for high-quality combined care. HOW TO CITE THIS ARTICLE: Tripathy LN, Rana I, Saha A, Dixit R. Takotsubo Cardiomyopathy Secondary to Ruptured Supraclinoid Internal Carotid Artery Aneurysm. Indian J Crit Care Med 2020;24(5):363-364.

Nondysraphic cervicomedullary intramedullary lipoma.

Spinal cord lipomas are usually associated with spinal dysraphism and is most common in lumbosacral region. Spinal intradural lipoma is a rare condition accounting for less than 1% of spinal cord tumours and is most prevalent in cervicodorsal region. Intramedullary spinal cord lipoma of cervical spine not associated with spinal dysraphism is one of the rarest lesions. They usually present insidiously with slowly progressive myelopathic deficits. We present a case of nondysraphic intramedullary spinal cord lipoma with exophytic component and intracranial extension. A 30 year male patient presented with wasting of muscles of left shoulder and left forearm with resultant weakness for last two months and myelopathic signs. Magnetic resonance imaging revealed a T1 hyperintense , T2 hypointense lesion on the dorsal aspect of cervical spinal cord with intracranial extension and exophytic component. There was no contrast enhancement, fat suppression image indicated a lipoma. The patient underwent cervical laminectomy with foramen magnum decompression with subtotal resection of intramedullary lipoma. Histopathology examination confirmed the diagnosis of lipoma. Subtotal resection of intramedullary lipoma is a reasonable and acceptable surgical option considering the benign nature of lesion and high probability of neurological deterioration due to dense adhesion between lipoma and neural tissue.

Chronic Pseudomonas aeruginosa cervical osteomyelitis.

Pseudomonas aeruginosa is a rare cause of osteomyelitis of the cervical spine and is usually seen in the background of intravenous drug use and immunocompromised state. Very few cases of osteomyelitis of the cervical spine caused by pseudomonas aeruginosa have been reported in otherwise healthy patients. This is a case presentation of a young female, who in the absence of known risk factors for cervical osteomyelitis presented with progressively worsening neurological signs and symptoms.

Variant allele frequency enrichment analysis in vitro reveals sonic hedgehog pathway to impede sustained temozolomide response in GBM.

Neoplastic cells of Glioblastoma multiforme (GBM) may or may not show sustained response to temozolomide (TMZ) chemotherapy. We hypothesize that TMZ chemotherapy response in GBM is predetermined in its neoplastic clones via a specific set of mutations that alter relevant pathways. We describe exome-wide enrichment of variant allele frequencies (VAFs) in neurospheres displaying contrasting phenotypes of sustained versus reversible TMZ-responses in vitro. Enrichment of VAFs was found on genes ST5, RP6KA1 and PRKDC in cells showing sustained TMZ-effect whereas on genes FREM2, AASDH and STK36, in cells showing reversible TMZ-effect. Ingenuity pathway analysis (IPA) revealed that these genes alter cell-cycle, G2/M-checkpoint-regulation and NHEJ pathways in sustained TMZ-effect cells whereas the lysine-II&V/phenylalanine degradation and sonic hedgehog (Hh) pathways in reversible TMZ-effect cells. Next, we validated the likely involvement of the Hh-pathway in TMZ-response on additional GBM neurospheres as well as on GBM patients, by extracting RNA-sequencing-based gene expression data from the TCGA-GBM database. Finally, we demonstrated TMZ-sensitization of a TMZ non-responder neurosphere in vitro by treating them with the FDA-approved pharmacological Hh-pathway inhibitor vismodegib. Altogether, our results indicate that the Hh-pathway impedes sustained TMZ-response in GBM and could be a potential therapeutic target to enhance TMZ-response in this malignancy.