[Show abstract][Hide abstract] ABSTRACT: Background: Aneurysms of proximal (A1)-segment of anterior cerebral artery (ACA) constitute <1% of all intracranial aneurysms. Aim: Management dilemmas of A1-segment aneurysms were studied utilizing a new classification based upon their location on the longitudinal and circumferential axis of A1-segment. Setting and Design: Tertiary care referral center. Materials and Methods: This is a retrospective analysis of 14 patients (0.98%; mean age: 38.02 ± 15.74 years) with A1-segment aneurysms. The data collected included clinical features, computed tomography (CT) scan and CT-angiography (CTA)/digital subtraction angiography (DSA) findings, modified Hunt and Hess (H and H) grade, surgical steps and difficulties encountered. Results: The modified Hunt and Hess (H and H) grades in the 14 patients were: grade I in two, grade II in two, grade III in four, grade IV in five and grade V in 1. The mean ictus-admission duration was 5.07 ± 2.30 days (range: 1-10 days). Multiple aneurysms were two. Thirteen patients underwent clipping and one, wrapping. Bilateral lateral ventricle hemorrhage occurred in 8 (66%) patients and frontal intracerebral hematoma in 2 (16.66%) patients. In one patient, the aneurysm could only be detected following the third angiogram. A1-aneurysms were classified as proximal (n = 6), distal (n = 7), and mid-segment (n = 1); and, anterior (n = 2), posterior-inferior (n = 7) and posterior-superior (n = 5). Follow-up (range: 6 months-10 years, mean: 2.9 years) recovery (assessed using Modified Rankin's score or mRS) correlated with preoperative status. The preoperative H and H grade and follow-up mRS status were as follows: H and H I (n = 2): mRS 0 (asymptomatic, n = 2); H and H II (n = 2): mRS 1 (minor symptoms without disability, n = 2); H and H III (n = 4):mRS 1 (n = 2) and mRS 2 (slight disability but performing unassisted activities of daily living, n = 1); H and H IV (n = 5): mRS 3 (moderate disability, requiring help for daily living but unassisted walking, n = 2) and mRS 4 (moderately severe disability, requiring help for daily living and walking, n = 2). One patient each from H and H grade III, IV and V died (mRS 6) during treatment due to severe vasospasm, pneumonitis and septicemia. Conclusions: A1-segment aneurysms have unique properties: rupturing of small-sized aneurysms; multiplicity; undetectable on initial imaging; frontal lobar/intraventricular bleeding; origin from main trunk and not bifurcating points; neck obscuration by A1-trunk; close proximity to perforators; and, associated A1-segment and ACA anomalies. A new classification identifies surgical difficulties inherent in different sites of origin of A1-aneurysms.
Neurology India 07/2014; 62(4):410-416. · 1.04 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Spinal intramedullary tuberculoma (SIT) is a rare manifestation of neurotuberculosis. Concurrent SIT and intracranial tuberculoma are further unusual. Most of these tuberculomas respond completely to medical therapy, and surgical excision is seldom required. In this report, we describe a 17-year-old boy who developed cervical intramedullary tuberculoma at C3-C6 level with a concurrent lesion involving the right cerebellar hemisphere while on treatment for tubercular meningitis. This patient had paradoxical increase in size of the cervical lesion even though the cerebellar lesion showed regression in size. In this article, we discuss the paradoxical response to anti-tubercular therapy in central nervous system tuberculosis, possible causes of nonresolution of tuberculoma on medical therapy and evaluate the role of surgery in these cases.
Journal of Pediatric Neurosciences 05/2014; 9(2):162-5.
[Show abstract][Hide abstract] ABSTRACT: Surgical excision of rare, large-to-giant posterior third ventricular (PTV) meningiomas [including velum-interpositum meningiomas (VIM; postero-superior venous complex displacement; without falco-tentorial attachment) and falco-tentorial meningiomas (FTM; falco-tentorial attachment; displacing major veins antero-inferiorly)] is extremely challenging. To study the management nuances in the excision of large-to-giant PTV meningiomas. Tertiary care referral center. Four patients with large (>3 cm; n = 2) and giant (>5 cm; n = 2) meningiomas (FTM = 2; VIM = 2, mean tumor size = 4.9 cm) underwent occipital transtentorial approach (OTT) for tumor excision. One also underwent a second-stage supracerebellar infratentorial (SCIT) approach. The side of approach was determined by lateral tumor extension and venous displacement (right = 3, left = 1). Near-total removal or subtotal excision (<10% remaining) with radiotherapy was performed in 2 patients each, respectively. At follow-up (mean: 14.75 months), clinical improvement without tumor recurrence/re-growth was achieved. Extent of excision was determined by position of great vein of Galen; tumor attachment to falco-tentorium or major veins; its consistency; its lateral and inferior extent; and, presence of a good tumor-neuraxial arachnoidal plane. OTT is the preferable approach for large-to-giant meningiomas as it provides a wider corridor and better delineation of tumor-neurovascular arachnoidal interface.
Neurology India 05/2014; 62(3):290-5. · 1.04 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Increased glycine concentration in the brain is associated with altered metabolism in cancer and can be detected by using in vivo MR spectroscopy. This has been proposed as a marker for grade IV gliomas; however, little is known about the potential significance and frequency of in vivo glycine observation. The purpose of this study was to examine the rate of occurrence and spatial distribution of glycine observation with respect to other MR imaging parameters.
Data from volumetric whole-brain MR spectroscopic imaging of 59 subjects with glioma were analyzed with glycine included in the spectral model. The associations of the signal amplitude and spatial distributions of glycine with findings from contrast-enhanced T1, perfusion, and diffusion MR imaging were then examined.
Glycine was detected in 24% of all studies, though with a wide range of signal amplitude and extent of the spatial distributions. While more commonly seen in grade IV tumors (42% of studies), relatively large concentrations were also detected in grade II and III gliomas. Coanalysis with other metabolites indicated a strong association with choline and that glycine was frequently seen to be overlapping with, and adjacent to, areas of high lactate concentration. Increased glycine was always associated with contrast enhancement and areas of increased cerebral blood flow, but without any clear association with other image parameters.
Detection of increased glycine in gliomas appears to identify a subgroup of tumors and areas of increased proliferation.
American Journal of Neuroradiology 01/2014; · 3.17 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: In some cases of spontaneous subarachnoid hemorrhage (SAH), the cause of bleed remains obscure on initial evaluation. These patients may harbor structural lesions. We aim to determine the utility of repeat angiogram in these subsets of patients.
Surgical Neurology International 01/2014; 5:125. · 1.18 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: We report a rare case of a post-traumatic subdural hygroma occurring with a giant frontotemporal arachnoid cyst in a 6-year old child and discuss its pathogenesis and management implications. Awareness regarding the association of a subdural hygroma associated with an arachnoid cyst is of immense clinical importance as the former may precipitate intracranial hypertension in a previously asymptomatic arachnoid cyst and yet may remain undetectable on a CT scan.
[Show abstract][Hide abstract] ABSTRACT: Studies of brain tumors have identified altered tissue metabolism and water diffusion in MRI normal appearing tissue regions. In this retrospective study the relationship of these imaging measures with tumor grade in gliomas was investigated.
MR spectroscopic imaging of whole brain and mean diffusivity (MD) measurements were obtained in subjects with untreated glioma and from normal control subjects. Mean metabolite values for N-acetylaspartate (NAA), total creatine (Cre), and total choline (Cho) were obtained in gray- and white-matter regions for the hemisphere contralateral to the tumor location, and MD values were obtained from contralateral normal-appearing white matter. Analyses tested for differences in mean values between subject groups while accounting for age.
Analysis demonstrated increased NAA/Cre and MD, and decreased Cho/NAA for all tumor grades relative to control values. Differences between tumor grades were also observed for NAA, NAA/Cre, and Cho/NAA. Abnormal values of water diffusion were also observed, but with only a weak association between alterations in diffusion and tissue metabolites.
This study supports previous observations of altered tissue metabolism and water diffusion in normal-appearing white matter while additionally finding differences of metabolite values in gray matter and an association with tumor grade.
Journal of neuroimaging: official journal of the American Society of Neuroimaging 11/2013; · 3.36 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: A wide variety of congenital anomalies are observed around the craniovertebral junctional area. However, hypertrophied unilateral lateral mass of atlas in association with chiari-1 malformation leading to myelopathy is extremely uncommon. Herein we report a case of 28-year-old female who presented to us with a high cervical compressive myelopathy. Imaging revealed bony hypertrophy involving right sided C1 lateral mass along with chiari malformation-type 1. She underwent transoral as well as posterior decompression followed by occipito-cervical fusion. The authors discuss their case in light of other such reported cases and present a review of the literature.
Journal of craniovertebral junction and spine 07/2013; 4(2):73-5.
[Show abstract][Hide abstract] ABSTRACT: Osteoblastoma (OB) is a rare bony neoplasm constituting around 1% of all primary bone tumors. Although the vertebrae and long bones are the most common sites affected by OB, skull remains a relatively uncommon site of occurrence. Aggressive variant of OB is histologically intermediate between an indolent conventional OB and a malignant osteosarcoma. To the best of our knowledge, aggressive osteoblastoma (AO) affecting the craniovertebral junction has not been previously described in the literature. In this report, we present a 34-year-old gentleman who presented with a mass involving the left side of the neck and oral cavity along with ipsilateral lower cranial nerve paresis. Computed tomography and magnetic resonance imaging scans of the craniovertebral junction revealed a heterogeneously enhancing expansile lesion with areas of destruction involving the clivus, left sided jugular foramen and left side of first two cervical vertebras. Angiography showed distortion of the V3 segment of the left vertebral artery and shift of the ipsilateral internal carotid artery. The tumor was maximally excised through far lateral approach. Histopathologic examination revealed a diagnosis of AO. The patient was referred for radiotherapy for the residual tumor and was doing well at 5 months follow-up.
Journal of craniovertebral junction and spine 07/2013; 4(2):69-72.
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND: This prospective study attempts to study the clinico-radiological differences between patients with syndromic AAD (SAAD), non-syndromic AAD (NSAAD), and AAD with Klippel-Feil anomaly (AADKFA) that may impact management. METHODS: In 46 patients with AAD [SAAD (including Morquio, Down, Larson and Marshall syndrome and achondroplasia; n = 6); NSAAD(n = 20); and, AADKFS (n = 20)], myelopathy was graded as mild (n = 17, 37 %), moderate (15, 32.5 %) or severe (14, 30.5 %) based on Japanese Orthopaedic Association Score modified for Indian patients (mJOAS). Basilar invagination (BI), basal angle, odontoid hypoplasia, facet-joint angle, effective canal diameter, Ishihara curvature index, and angle of retroversion of odontoid and vertebral artery (VA) variations were also studied. STATISTICS: Clinico-radiological differences were assessed by Fisher's exact test, and mean craniometric values by Kruskal-Wallis test (p value ≤ 0.05 significant) RESULTS: Incidence of irreducible AAD in SAAD (n = 0), NSA AD (11.55 %) and AADKFS (n = 18.90 %) showed significant difference (p = 0.01). High incidence of kyphoscoliosis (83 %) and odontoid hypoplasia (83 %) in SAAD, and assimilated atlas and BI in NSAAD and AADKFA groups were found. In AADKFA, effective canal diameter was significantly reduced(p = 0.017) with increased Ishihara index and increased angle of odontoid retroversion; 61 % patients had VA variations. Thirty-five patients underwent single-stage transoral decompression with posterior fusion (for irreducible AAD) or direct posterior stabilization (for reducible AAD). Postoperative mJOAS evaluation often revealed persistent residual myelopathy despite clinical improvement. CONCLUSIONS: Myelopathy is induced by recurrent cord trauma due to reducible AAD in SAAD, and compromised cervicomedullary canal diameter in NSAAD and AADKFA. SAAD in children may be missed due to incomplete odontoid ossification or coexisting angular deformities. In AADKFA, decisions regarding vertebral levels to be included in posterior stabilization should take into consideration intact intervening motion segments and compensatory cervical hyperlordosis. Following VA injury, endovascular primary vessel occlusion/stenting across pseudoaneurysm preempts delayed rehemorrhage.
[Show abstract][Hide abstract] ABSTRACT: INTRODUCTION: Accurate grading of cerebral glioma using conventional structural imaging techniques remains challenging due to the relatively poor sensitivity and specificity of these methods. The purpose of this study was to evaluate the relative sensitivity and specificity of structural magnetic resonance imaging and MR measurements of perfusion, diffusion, and whole-brain spectroscopic parameters for glioma grading. METHODS: Fifty-six patients with radiologically suspected untreated glioma were studied with T1- and T2-weighted MR imaging, dynamic contrast-enhanced MR imaging, diffusion tensor imaging, and volumetric whole-brain MR spectroscopic imaging. Receiver-operating characteristic analysis was performed using the relative cerebral blood volume (rCBV), apparent diffusion coefficient, fractional anisotropy, and multiple spectroscopic parameters to determine optimum thresholds for tumor grading and to obtain the sensitivity, specificity, and positive and negative predictive values for identifying high-grade gliomas. Logistic regression was performed to analyze all the parameters together. RESULTS: The rCBV individually classified glioma as low and high grade with a sensitivity and specificity of 100 and 88 %, respectively, based on a threshold value of 3.34. On combining all parameters under consideration, the classification was achieved with 2 % error and sensitivity and specificity of 100 and 96 %, respectively. CONCLUSION: Individually, CBV measurement provides the greatest diagnostic performance for predicting glioma grade; however, the most accurate classification can be achieved by combining all of the imaging parameters.
[Show abstract][Hide abstract] ABSTRACT: Nerve sheath myxoma (neurothekeoma) are rare benign nerve sheath tumors, usually arising in the skin of the head and neck region and upper extremities in young females. To the best of author's knowledge only two cases of intracranial neurothekeoma have been published in the English literature. These tumors were located in the parasellar area and in middle cranial fossa. This is the first case report of cerebellopontine angle neurothekeoma and third case report of intracranial neurothekeoma. This patient, a 45-year-old female, presented to us with complaints of right side progressive hearing loss for 12 months and swaying during walking for 8 months. Histologically the tumor had lobular appearance with spindle or stellate cells embedded in abundant myxoid background. The tumor cells were diffusely positive for S100. The patient was symptom free at eight month follow up.
[Show abstract][Hide abstract] ABSTRACT: Choroid plexus tumors are intraventricular tumors derived from choroid plexus epithelium.
To study the choroid plexus tumors with reference to their clinical, radiological, and pathological features.
The study was performed by the retrospectively reviewing the clinical, radiological, and pathological records of patients of choroid plexus tumors.
A total of 23 cases (11 males, 13 females) of choroid plexus tumor were diagnosed from 1997 to 2009. Fourteen patients were below 15 years of age. Raised intracranial pressure was the main presenting feature in all the cases. Tumor was located in lateral ventricle (n = 14; in 3 cases tumor was going into third ventricle), fourth ventricle (n = 7), and cerebellopontine angle (n = 2). Total tumor excision was achieved in 21 cases. The histopathology was suggestive of choroid plexus papilloma (n = 19), atypical choroid plexus papilloma (n = 1), and choroid plexus carcinoma (n = 2). Clears cell areas were noted in three cases. Other histopathological features observed were foci of calcification (n = 5), Psammoma bodies (n = 2), hemorrhage (n = 5), hyalinization (n = 2), and oncocytic changes (n = 1).
Choroid plexus tumors are intraventricular tumors arising from choroid plexus epithelium. The predominant clinical presentation is raised intracranial pressure. Surgery is the mainstay of treatment; histopathologically, they include choroid plexus papilloma, atypical choroid plexus papilloma, and choroid plexus carcinoma.
Asian journal of neurosurgery. 01/2013; 8(1):29-35.
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND: Hyperproteinorrhachia associated with vestibular schwannomas (VSs) may influence visual status independent of the effect caused by raised intracranial pressure. The role of cisterna magna CSF protein levels (CMCP) in determining visual outcome in patients with large to giant vestibular schwannomas (VSs) was prospectively investigated. METHODS: The mean CMCP levels in VSs and control group; and, levels in VSs with or without visual deterioration were compared. Spearman's rank correlation coefficient tested for relationships between CMCP level with symptom duration and tumour volume (Kawamoto's method). Vision was regarded as normal when visual acuity was >6/18; and, deteriorated when it was between 6/18 and PL negative in the worse eye. Papilloedema (n = 26)/secondary optic atrophy (n = 6) and hydrocephalus (based on Evan's ratio, mild to moderate: n = 22; none: n = 18) were also recorded. The analysis of factors predicting diminished vision was done using logistic regression analysis (p < 0.05 significant). FINDINGS: There was a significant difference (p < 0.001) in mean CMCP levels between VS (456.3 SD 213.6 mg/dl) and control groups (96.3 SD 74.3 mg/dl). The mean CMCP levels in the VS group were also markedly higher than the ventricular mean protein levels. The CMCP levels in patients with visual diminution (<6/18 to PL negative; n = 23) was 561.4 SD 186.9 mg/dl and those without visual loss (n = 17) was 314.2 SD 160.8 mg/dl (p < 0.001). Their grade of visual diminution had a positive correlation with mean CMCP levels (p < 0.001). There was a negative correlation between total duration of symptoms and CMCP levels (p < 0.015). Logistic regression analysis using five independent factors (symptom duration, papilloedema/secondary optic atrophy, tumour volume, hydrocephalus and mean CMCP level) revealed that only CMCP level had a significant association with visual diminution. CONCLUSION: Elevated cisternal CSF proteins may play an important role in determining visual outcome in large to giant VSs. Ventricular CSF analysis is often unable confirm the presence of VS-associated cisternal hyperproteinorrhachia. High CMCP levels may influence decision-making while instituting a permanent CSF diversion for postoperative hydrocephalus or recalcitrant pseudomeningocoele.
[Show abstract][Hide abstract] ABSTRACT: In this study, three primary central nervous system tumors of different histological cell types occurring together without neurofibromatosis are reported. These included a sellar pituitary adenoma with apoplexy, a large torculo-tentorial meningioma in the posterior fossa, and a cervical spinal intramedullary schwannoma. Displacement of primitive multipotent cells in different central nervous system compartments or the oncogenic effects of activated signaling of growth factor receptors are the proposed pathophysiological mechanisms for the simultaneous genesis of different types of tumors. There was associated tonsillar herniation, cervicodorsal syringomyelia, and hydrocephalus. The radiological features and treatment strategy of these rare synchronous tumors are highlighted.
Indian Journal of Surgery 10/2012; 74(5):420-421. · 0.09 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Intraoperative consultation is an important component in the surgical management of brain tumors. This study was undertaken to describe the cytomorphological features of central neurocytoma (CN) in squash smears. Squash smear of five CNs were reviewed. One to two millimeters of the biopsy material was crushed between two glass slides to make a thin film that was fixed in 95% alcohol and stained with haematoxylin and eosin (H&E). Cytological diagnoses were correlated with clinical and radiological data and finally with histopathological findings in the tumor. We had 5 cases (4 males, 1 female; age, 19-61 years; mean, 32 years). All tumors were located in the lateral ventricle. The smears were highly cellular displaying monomoprhic round tumor cells, round to oval nuclei with evenly distributed finely granular chromatin and ill-defined cytoplasmic borders within fibrillar matrix. Focal rosette formation is also noted. A capillary network was identified in between tumor cells in all the cases. One case had calcification with numerous psamomma bodies identified in the squash smear. The differential diagnosis is discussed. On squash smears, CN can be diagnosed when cytomorphological features are correlated with clinical and radiological finding.