Giant Bilateral Calvarial Hyperostosis Secondary to Small Unilateral Frontal Meningioma.

A 28-year-old male patient presented to us with bilateral frontal hyperostosis associated with a small unilateral frontal intracranial meningioma. He underwent successful excision of the involved bone and repair of the large cranial defect using a titanium mesh. Histological examination revealed tumor infiltration of the overlying bone. Surgical challenges in the management of such a case are also discussed.

Comparison of Stereotactic and Ultrasound-guided Biopsy of Solid Supratentorial Tumor: A Preliminary Report.

INTRODUCTION: The computed tomography (CT) guided stereotactic biopsy (STB) is considered as method of choice for biopsy of intracranial mass lesions. However, it's disadvantages are frame fixation, time requirement for transportation between CT scan suit to the operation theater with added much higher equipment cost in the relatively resource scarred developing country. Ultrasound-guided biopsy (USGB) is relatively simpler, economical, less time consuming, and real-time procedure. CLINICAL MATERIALS AND METHODS: Thirty-seven consecutively admitted patients with supratentorial brain tumors, who underwent biopsy of the lesion using CT compatible stereotactic and ultrasound-guided (USGB) procedure formed cohort of the study. Based on location and size of the lesions, the cases were divided into two groups, superficial and deep. Twenty-two patients underwent ultrasound-guided biopsy and 15 with STB. RESULTS: The diagnostic yield of STB was 93% and 91% for ultrasound-guided biopsy. The mean operation time of STB group was 149.00 min and 94 min for USGB, which was statistically significant. Two cases in each group developed hematoma; however, one case in USGB group needed surgical evacuation. The real-time monitoring detected two hematoma intraoperatively, which were further also confirmed on postoperative CT scan head. CONCLUSIONS: The ultrasound-guided biopsy procedure (USGB) was simple, relatively shorter time-consuming procedure and equally efficacious and utilizing economical equipment and can act as a safer alternative to CT STB process for biopsy of the intracranial mass lesion. Furthermore, USGB also provided intra-operative real-time monitoring, which provided clue for close monitoring in the postoperative period after completion of biopsy to look for development of fresh hematoma development not only at the biopsy site but also along the biopsy track and adjoining area. Perhaps, a longer period of ultrasonic monitoring following the procedure would be of greater help to detect hematoma formation, which is one of the most common complications of the biopsy procedure.

Acute unilateral post-operative submandibular sialadenitis following posterior cranial fossa surgery.

Extreme degree of rotation and flexion of the head during posterior fossa surgeries can lead to acute post-operative submandibular sialadenitis that can cause respiratory compromise. Identification of this problem is vital to prevent deterioration in the early post-operative period. This condition responds well to conservative management provided airway obstruction is taken care of. We discuss a case of a 63-year-old female, with a left side vestibular schwannoma who developed airway obstruction in post-operative period due to swelling of right submandibular gland. Various possible mechanisms leading to this condition and related literature are briefy reviewed.

Primary dorsal spine primitive neuroectodermal tumor in an adult patient: Case report and literature review.

Primary spinal primitive neuroectodermal tumor (psPNET) is a rare entity with few cases reported in literature. We report a case of a 50-year-old female who presented to us with paraplegia and was diagnosed with extradural dorsal spine psPNET. The diagnosis was not suspected at presentation or on radiology but was established on histopathological examination. It is important to distinguish it from central nervous system primitive neuroectodermal tumors and from other spinal tumors since it follows a different clinical course and therapeutic outcome.

Pilocytic Midbrain Astrocytoma Presenting with Fresh Bleed after Twenty-one-years Survival Following First Surgery: A Unique Case of Longest Brainstem Glioma Survival.

Brainstem glioma usually carries a poor prognosis and prolonged survival is very infrequent. In a detailed Pubmed, Medline search for prolonged survival, authors could got a longest survival only up to seventeen years, reported by Umehara et al, who was subjected to gamma knife therapy and got symptomatic, MRI brain reveled large tumor growth during pregnancy necessitating emergency surgery and histopathological diagnosis was pilocytic astrocytoma. Authors report an interesting case of midbrain glioma diagnosed 21 years back, who underwent gross resection in the year 1993, histopathology was pilocytic astrocytoma, WHO grade I, and received gamma knife surgery for residual subsequently and he presented with sudden onset left sided hemiplegia on the current admission. The cranial MRI imaging revealed an infarct involving right hemi midbrain, contrast MRI brain revealed no residual glioma. To the best knowledge of authors such prolonged survival is not reported with a case of brainstem glioma survived twenty- one years with non residual tumor on the last imaging study represents first case of its kind in the western literature and probably developed hemiplegia due to bleed, highlighting bleed as delayed complication following gamma knife therapy for cranial tumors.

PPARγ regulated CIDEA affects pro-apoptotic responses in glioblastoma.

Refractoriness of glioblastoma multiforme (GBM) to current treatment paradigms has necessitated identification of new targets to better the existing therapeutic strategies. One such target is peroxisome proliferator-activated receptor gamma (PPARγ) - a transcription factor involved in regulation of lipid metabolism and inflammation. Expression of PPARγ, a known regulator of cell death-inducing DFFA-like effector (CIDEA), is modulated by hypoxia inducible factor (HIF-1α). While the involvement of CIDEA in lipid metabolism is known, its role in malignancies remains largely unknown. An elevated PPARγ and low CIDEA level was observed in GBM tumors as compared with surrounding non-neoplastic tissue. As reciprocal relation exists between PPAR and HIF-1α: and as HIF-1α is a key component in glioma progression, their role in regulating CIDEA expression in glioblastoma was investigated. Although HIF-1α inhibition had no effect on CIDEA expression, pharmacological inhibition of PPARγ elevated CIDEA levels. PPARγ mediated upregulation of CIDEA was accompanied by decreased recruitment of NFκB and SP1 to their predicted binding sites on CIDEA promoter. Ectopic expression of CIDEA triggered apoptosis, activated JNK, decreased HIF-1α activation and increased PPARγ levels in glioma cells. While CIDEA overexpression induced actin cytoskeletal disruption, cell cycle arrest, release of pro-inflammatory cytokine IL-6 in a JNK-dependent manner; CIDEA mediated apoptotic cell death, decreased STAT3 phosphorylation and increased p53 acetylation was JNK independent. This study highlights for the first time the existence of (i) PPARγ-CIDEA regulatory loop in glioma and (ii) novel function of CIDEA as regulator of glioma cell survival.

Stem cell therapy for stress urinary incontinence: a systematic review in human subjects.

PURPOSE: To systematically evaluate the current evidence on the safety and efficacy of stem cell therapy (SCT) in stress urinary incontinence (SUI) to allow objective comparison with existing surgical techniques. METHODS: Systematic literature search of Medline from years 1946-2012 using terms: "stem", "cell", "stress", "urinary", and "incontinence". Included studies presented empirical data on the treatment of SUI using SCT. OUTCOMES: adverse events, incontinence, quality of life, urodynamic, transurethral ultrasound and urethral EMG findings. RESULTS: Eight studies met inclusion criteria (seven observational and one randomized). Quality score: median 10.75 of 20 (range 2-12.5). Adverse events: one patient had bladder perforation and two procedures could not be completed due to pain. Temporary urinary retention and cystitis were also reported. Incontinence score: Four studies describe significant improvement. Quality of life: significant improvement in four studies. Urodynamic outcomes: four studies show significant improvement in contractility of urethral sphincter; three studies demonstrate no change in bladder capacity and significant reduction in residual volume; significant improvement in urinary flow three studies, although two found no difference; increase in leak point pressure and detrusor pressure in three studies. Urethral ultrasound: three studies found significant increases in rhabdosphincter thickness and contractility. Urethral EMG: two studies found significant increases in the EMG at rest and at contraction. CONCLUSION: Data suggest that SC treatment for SUI is safe and effective in the short term. However, the quality and maturity of the data are limited. Robust data from better quality studies comparing this to current surgical techniques are needed.

Spinal dural arterio-venous fistula: clinico-radiological profile and outcome following surgical occlusion in an Indian neurosurgical center.

BACKGROUND: Spinal dural arteriovenous fistula (SDAVF) is a common type of spinal vascular lesion. However, there has not been any published study on its clinico-radiological characteristics or surgical outcome from India. AIM: The aim of this study was to determine the clinico-radiological features of patients with SDAVF, outcomes following surgical ligation of the fistula and the various factors involved. MATERIALS AND METHODS: Patients who were operated for SDAVF were studied for demographic details, symptoms, clinical severity, radiological features and neurological outcome in the form of improvement in gait disability grades. Appropriate statistical tests were performed. RESULTS: There were 22 (19 males, 3 females) patients of SDAVF who underwent surgical ligation with a mean age of 55 years. The mean duration of symptoms at presentation was 15 months. Three patients had acute onset while the rest had insidious onset of symptoms. Out of the 22 patients, 11 (50%) had motor weakness as the first symptom, 13 (59%) were bedridden and 19 (86.4%) had bladder involvement at presentation. Thirteen patients had fistulae in thoracic spine, whereas eight had fistulae in the lumbar spine. All had a favorable outcome in the form of at least non-progression of gait disability (14 had improvement while 8 had stabilized). The improvement was non-significantly associated with younger age, acute onset, ambulant status and fistula below T9. It was inversely associated with pain as the first symptom and fluctuant clinical course. CONCLUSION: Surgical occlusion of SDAVF is usually associated with either improvement or stabilization of motor weakness.

ATM-NFκB axis-driven TIGAR regulates sensitivity of glioma cells to radiomimetics in the presence of TNFα.

Gliomas are resistant to radiation therapy, as well as to TNFα induced killing. Radiation-induced TNFα triggers Nuclear factor κB (NFκB)-mediated radioresistance. As inhibition of NFκB activation sensitizes glioma cells to TNFα-induced apoptosis, we investigated whether TNFα modulates the responsiveness of glioma cells to ionizing radiation-mimetic Neocarzinostatin (NCS). TNFα enhanced the ability of NCS to induce glioma cell apoptosis. NCS-mediated death involved caspase-9 activation, reduction of mitochondrial copy number and lactate production. Death was concurrent with NFκB, Akt and Erk activation. Abrogation of Akt and NFκB activation further potentiated the death inducing ability of NCS in TNFα cotreated cells. NCS-induced p53 expression was accompanied by increase in TP53-induced glycolysis and apoptosis regulator (TIGAR) levels and ATM phosphorylation. siRNA-mediated knockdown of TIGAR abrogated NCS-induced apoptosis. While DN-IκB abrogated NCS-induced TIGAR both in the presence and absence of TNFα, TIGAR had no effect on NFκB activation. Transfection with TIGAR mutant (i) decreased apoptosis and γH2AX foci formation (ii) decreased p53 (iii) elevated ROS and (iv) increased Akt/Erk activation in cells cotreated with NCS and TNFα. Heightened TIGAR expression was observed in GBM tumors. While NCS induced ATM phosphorylation in a NFκB independent manner, ATM inhibition abrogated TIGAR and NFκB activation. Metabolic gene profiling indicated that TNFα affects NCS-mediated regulation of several genes associated with glycolysis. The existence of ATM-NFκB axis that regulate metabolic modeler TIGAR to overcome prosurvival response in NCS and TNFα cotreated cells, suggests mechanisms through which inflammation could affect resistance and adaptation to radiomimetics despite concurrent induction of death.

Inhibition of Casein kinase-2 induces p53-dependent cell cycle arrest and sensitizes glioblastoma cells to tumor necrosis factor (TNFα)-induced apoptosis through SIRT1 inhibition.

Glioblastoma multiforme (GBM) are resistant to TNFα-induced apoptosis and blockade of TNFα-induced NF-κB activation sensitizes glioma cells to apoptosis. As Casein kinase-2 (CK2) induces aberrant NF-κB activation and as we observed elevated CK2 levels in GBM tumors, we investigated the potential of CK2 inhibitors (CK2-Is) - DRB and Apigenin in sensitizing glioma cells to TNFα-induced apoptosis. CK2-Is and CK2 small interfering RNA (siRNA) reduced glioma cell viability, inhibited TNFα-mediated NF-κB activation, and sensitized cell to TNFα-induced apoptosis. Importantly, CK2-Is activated p53 function in wild-type but not in p53 mutant cells. Activation of p53 function involved its increased transcriptional activation, DNA-binding ability, increased expression of p53 target genes associated with cell cycle progression and apoptosis. Moreover, CK2-Is decreased telomerase activity and increased senescence in a p53-dependent manner. Apoptotic gene profiling indicated that CK2-Is differentially affect p53 and TNFα targets in p53 wild-type and mutant glioma cells. CK2-I decreased MDM2-p53 association and p53 ubiquitination to enhance p53 levels. Interestingly, CK2-Is downregulated SIRT1 activity and over-expression of SIRT1 decreased p53 transcriptional activity and rescued cells from CK2-I-induced apoptosis. This ability of CK2-Is to sensitize glioma to TNFα-induced death via multiple mechanisms involving abrogation of NF-κB activation, reactivation of wild-type p53 function and SIRT1 inhibition warrants investigation.

Dengue hemorrhagic fever: a rare cause of pituitary tumor hemorrhage and reversible vision loss.

Dengue hemorrhagic fever leading to hemorrhage in pituitary adenoma is not reported till date: We herein report the first case of bilateral visual loss secondary to pituitary adenoma hemorrhage associated with dengue hemorrhagic fever. Urgent transnasal trans sphenoidal decompression of the macroadenoma prevented permanent visual loss in this patient. Pituitary apoplexy should be considered as differential diagnosis of visual deterioration apart from retinal hemorrhage, maculopathy, and optic neuropathy in cases of dengue hemorrhagic fever. Early decompression of optic nerves helped in the restoration of vision.

A cross-sectional evaluation of computer literacy among medical students at a tertiary care teaching hospital in Mumbai, Bombay.

BACKGROUND: Computer usage capabilities of medical students for introduction of computer-aided learning have not been adequately assessed. AIM: Cross-sectional study to evaluate computer literacy among medical students. SETTINGS AND DESIGN: Tertiary care teaching hospital in Mumbai, India. MATERIALS AND METHODS: Participants were administered a 52-question questionnaire, designed to study their background, computer resources, computer usage, activities enhancing computer skills, and attitudes toward computer-aided learning (CAL). The data was classified on the basis of sex, native place, and year of medical school, and the computer resources were compared. The computer usage and attitudes toward computer-based learning were assessed on a five-point Likert scale, to calculate Computer usage score (CUS - maximum 55, minimum 11) and Attitude score (AS - maximum 60, minimum 12). The quartile distribution among the groups with respect to the CUS and AS was compared by chi-squared tests. The correlation between CUS and AS was then tested. RESULTS: Eight hundred and seventy-five students agreed to participate in the study and 832 completed the questionnaire. One hundred and twenty eight questionnaires were excluded and 704 were analyzed. Outstation students had significantly lesser computer resources as compared to local students (P<0.0001). The mean CUS for local students (27.0±9.2, Mean±SD) was significantly higher than outstation students (23.2±9.05). No such difference was observed for the AS. The means of CUS and AS did not differ between males and females. The CUS and AS had positive, but weak correlations for all subgroups. CONCLUSION: The weak correlation between AS and CUS for all students could be explained by the lack of computer resources or inadequate training to use computers for learning. Providing additional resources would benefit the subset of outstation students with lesser computer resources. This weak correlation between the attitudes and practices of all students needs to be investigated. We believe that this gap can be bridged with a structured computer learning program.

Outcome following surgery for ophthalmic segment aneurysms.

Ophthalmic segment aneurysms account for about 5% of all intracranial aneurysms. Anatomical complexity of the paraclinoid region makes surgical management of aneurysms arising from the ophthalmic segment challenging. This study was carried out to assess the presenting features, complications and outcomes after surgical treatment of ophthalmic segment aneurysms. The authors retrospectively analysed the clinical records of patients with ophthalmic aneurysms treated at our Institute from January 2001 to September 2008, which constituted about 9% (78/850) of all intracranial aneurysms. Of the 78 ophthalmic segment aneurysms, six patients (8%) had giant aneurysms and 19 (24%) patients had multiple aneurysms. Fifty-six patients underwent microsurgery, with direct clipping in most. The mean age was 42 years (range 12-75 years) and the mean follow-up was 8 months (range, 2-93 months). A good outcome was achieved in 46 (83%) patients (Glasgow Outcome Scale [GOS] score 4-5) and 17% had a poor outcome (GOS score 1-3) at last follow-up. The overall complication rate was 21% (12/56), most of which were transient complications, with 3.5% (2/56) mortality. Direct microsurgical clipping remains our preferred treatment approach, whenever possible, for ophthalmic segment aneurysms. This surgery has an acceptable complication rate and leads to a good outcome in more than 80% of patients with ophthalmic aneurysms. Use of modern microsurgical instrumentation and endovascular adjuncts can further reduce the surgical morbidity associated with these vascular lesions.

Papillary tumor of the pineal region--a recently described entity: a report of three cases and review of the literature.

BACKGROUND: The papillary tumor of the pineal region (PTPR) is a distinct clinicopathologic entity, the exact biological behavior of which is not known. FINDING: In the present report we describe 3 additional cases of PTPR because of its rarity. During a study period of 4 years (between January 2003 and December 2006), we diagnosed three cases of papillary tumor of the pineal region (PTPR). Clinico-radio-pathologic examination was done and follow-up was assessed. Microscopically, all 3 cases showed uniform morphology and consisted of papillary and solid areas. Immunohistochemistry showed strong and diffuse positivity for synaptophysin, NSE, chromogranin A, S-100 protein, MAP-2 and cytokeratin. CONCLUSION: PTPR is a distinct entity and needs to be differentiated from other tumors of the pineal region as the biological behavior of this tumor is not fully understood. Radiologically this tumor can sometimes be misdiagnosed as tectal glioma.

Surgical considerations for 'intrinsic' brainstem gliomas: proposal of a modification in classification.

BACKGROUND: Brainstem gliomas are highly heterogeneous tumors both in their clinical manifestation and in their pathology. Despite significant advances in the surgery for brainstem gliomas many aspects of this pathology are still unclear. OBJECTIVE: To evaluate the clinical, radiological and surgical outcome of 40 focal 'intrinsic' brainstem gliomas and propose a surgical strategy-oriented classification. MATERIALS AND METHODS: A total of 40 focal 'intrinsic' ("expanding variety") tumors have been operated over a period of 8.5-years (January 1998-June 2007). Our criteria included patients with (1) well-defined gadolinium enhancing tumor; (2) relatively long duration of symptoms (> six months) and (3) good neurological functional status and independent for all activities of daily living. The cutoff size of 2 cm was not rigidly adhered to. RESULTS: The 'intrinsic' brainstem tumors were classified into three types: Expanding, diffuse infiltrative and pure ventral varieties. Only patients with expanding variety of brainstem gliomas were subjected to surgery, mean age 19.2 years (range 4-55 years) and male to female ration mean: 3:2). The tumor location included pons (n=19), midbrain (n=13) and medulla (n=8). Surgical approaches included midline suboccipital (n=28), retromastoid (n=7), subtemporal (n=3) and supracerebellar-infratentorial (n=2). Thirty-two cases with 'diffuse infiltrative' and 'pure ventral' variety were given radiotherapy only. Histology pathology revealed pilocytic variety (n=10), Grade II (n=17) and Grade III (n=13). There was one death in the surgical series (due to aspiration). Complications included meningitis (n=2), wound infection (n=1), chest infection (n=5) and transient mutism (n=1). Follow-up ranged from 3-68 months. Overall, 36 improved /remained same and three worsened in their clinical status at the time of discharge. CONCLUSION: The surgical management of intrinsic brainstem tumors presents a surgical challenge; radical excision yielded a good outcome in the majority of cases. The authors propose a classification system for 'intrinsic' brainstem tumors for defining surgical strategy.

Awake craniotomy versus surgery under general anesthesia for resection of intrinsic lesions of eloquent cortex--a prospective randomised study.

OBJECTIVES: Complete removal of a brain tumor without inflicting neurological deficits is a desirable end result in neurosurgical practice. Currently no prospective randomized surgical series in the literature exists comparing tumor resection under general versus local anesthesia awake surgery may achieve more aggressive tumor resection and minimize postoperative neurological morbidity. PATIENT AND METHODS: We thence conducted a prospective randomized comparative study of results of surgery under awake versus surgery under general anesthesia for intrinsic eloquent area lesions. Fifty-three patients with intrinsic brain tumors in eloquent areas were prospectively randomized (26 patients in awake group and 27 for surgery under general anesthesia). At 3 months follow up, 23% patients in awake group had permanent deficits compared to 14.8% in GA group. RESULTS: More than 90% tumor excision was observed in 57% patients in awake group versus 73.7% in GA group. CONCLUSIONS: The mean operative time, blood loss was found to be was found to be less in GA group patients than in awake group. Better tumor cytoreduction, neurological improvement was seen in GA group (motor improvement in 35.7%, speech improvement in 62.5%) than in awake group patients (motor improvement in 18.7%, speech improvement in 14.3%).