Preparation and comparative evaluation of 99mTc-labeled 2-iminothiolane modified antibodies and CITC-DTPA immunoconjugates of anti-EGF-receptor antibodies

The use of antibodies as targeting agents for the delivery of radioisotopes to tumors is a promising concept that has received widespread attention since the advent of monoclonal antibody (mAb) technology. The following studies are described in this article: the 99mTc-randiolabeling of 2-iminothiolane (2-IT) modified antibodies and 6-p-isothiocyanatobenzyl- diethylene-triamine penta-acetic acid (CITC-DTPA) immunoconjugates of anti-EGF-receptor antibodies murine ior egf/r3 and humanized h-R3; the analytical methods for quality control of the radiopharmaceutical such as instant thin layer chromatography-silica gel (ITLC-SG); the biological assessment of the radiolabeled molecule using flow cytometry analysis; in vitro stability studies with cysteine and DTPA challenge and the biodistribution studies in 4NMRI xenografted nude mice with U-87 human glioblastoma multiforme and MDA-MB-468 breast cancer cell lines. Labeling efficency of (96.48 +/- 0.70%) (98.42 +/- 0.38%), (94.8 +/- 1.25%) and (96.41 +/- 0.89%) was achieved for 99mTC-2-IT ior efg/r3, 99mTc-CITC-DTPA- ior egf/r3, 99mTc-CITC-DTPA- h-R3 and 99mTc-DIACIM h-R3, respectively. Radiocolloids were less than 2.0% in all cases. The biological activity measured by flow cytometry analysis using the MDA-MB-468 breast cancer cell line showed an immunoreactivity fraction greater than 85% in all concentrations of each immunoconjugate. Challenge studies demonstrated no evidence of transcomplexation of 99mTc to 1.0 mM DTPA for 2-IT modified antibody ior egf/r3 and CITC-DTPA immunoconjugates and only 8.7%, 4.9% and 5.0% of the 99mTc-radiolabeled was transcomplexed to 1.0 mM cysteine after 1 h incubation at 37 degrees C for 2-IT modified antibody ior egf/r3, CITC-DTPA ior egf/r3 and CITC-DTPA h-R3, respectively. Biodistribution studies with 2-IT modified antibodies and CITC-DTPA immunoconjugates indicated high tumor uptake in both cell lines with both immunoconjugates and no accumulation of the radiolabeled antibodies in normal organs.

Bilateral groove sign with penoscrotal elephantiasis

Lymphogranuloma venereum (LGV) is a sexually transmitted disease of the lymph channels caused by Chlamydia trachomatis. Esthiomene, a rare late manifestation of LGV, is a primary infection affecting the lymphatics of scrotum, penis, or vulva. The male genitalia are affected less commonly by esthiomene, but we report a male patient who presented with inguinal syndrome, penoscrotal elephantiasis, along with enlargement of femoral lymph nodes.

Lupus erythematosus profundus

A case of lupus erythematosus profundus, with associated mastitis, but without any lesions of discoid lupus erythematosus or systemic lupus erythematosus is being reported.

Congenital reducible atlantoaxial dislocation: classification and surgical considerations

BACKGROUND

Reducible atlanto-axial dislocation (AAD) may cause severe motor and respiratory compromise due to recurrent spinal cord and/or brain stem impingement. To the best of the authors' knowledge, this is the first study concentrating on the classification, the protocol of the surgical management and the outcome of congenital, reducible AAD.

METHODS

109 patients with congenital, reducible AAD underwent posterior stabilization. Their preoperative disability was graded as: I (n=11, 10.09%) no functional disability (a history of minor trauma led to quadriparesis that subsequently improved); II (n=31, 28.44%) independent for activities of daily living with minor disability; III (n=42, 38.53%) partially dependent on others for their daily needs; and, IV (n=25, 22.93%) totally dependent. They were classified into 4 groups depending upon their association with: a normal odontoid and posterior arch of atlas (n=27); a dysplastic odontoid and normal posterior arch (n=25); an assimilated posterior arch (n=49); and, Arnold Chiari malformation type I (n=8). Nine patients with a dysplastic odontoid had a "hypermobile" AAD with an unrestricted backward and forward movement of the axis relative to the atlas in flexion as well as in extension of the neck, respectively. The surgical procedures included Brooks' (n=12) or modified Brooks' C1-2 fusion (n=39); Goel's C1-2 fusion (3); Ransford's contoured rod fusion (n=7); Jain's occipitocervical fusion (n=47); and, transoral decompression and Jain's occipitocervical fusion (n=1). There were 6 peri-operative mortalities in the series.

FINDINGS

At follow-up (ranging from 3 months to 6 years; n=86), 64 patients had shown improvement by one grade or more; 8 patients, who had a history of transient quadriparesis but were without neurological deficits at presentation, remained in grade I; 11 had achieved stabilization of neurological functions; while 3 had deteriorated despite adequate radiological reduction of AAD and fusion of the construct. A follow-up of 6 months or more was available in 79 of these 86 patients, in whom a dynamic intrathecal CT scan showed a good osseous union.

INTERPRETATION

The patients with congenital reducible AAD, depending on their surgical management, may be classified into four groups. Some patients with a dysplastic odontoid have a "hypermobile" AAD and require special care during intubation, positioning and stabilization. An assimilated posterior arch is often associated with asymmetrical lateral occipito-C1-C2 joint synostosis rendering transarticular screw placement difficult. The various causes of failure of constructs are discussed.

Histoid leprosy with filariasis

A patient with filariasis, taking treatment in the form diethyl carbamazime citrate developing "de-novo" histoid leprosy during the course of the disease is being reported.

Inguinal syndrome with penoscrotal elephantiasis

Bilateral inguinal adenitis and penoscrotal elephantiasis are uncommonly encountered presentations of Lymphogranuloma venereum. Herein, we report a male who presented with bilateral inguinal bubos along with penoscrotal elephantiasis that developed within 6 months of the primary lesion.

Choroid plexus papillomas of the cerebellopontine angle

The cerebellopontine angle (CPA) is a rare site for the growth of choroid plexus papilloma (CPP). The clinicoradiological diagnosis of this tumor in the CPA is difficult because of the nonspecific clinical presentation and radiological features. Five cases of choriod plexus papilloma (3 males, 2 females) operated upon at this center are reviewed. All the cases were operated upon by retromastoid suboccipital craniectomy. As they all presented with a typical CPA syndrome without any distinctive radiological feature, a clinicoradiological diagnosis of CPP could not be reached in any of these. The diagnosis of CPP could only be suspected at the operation table and established on histopathological examination. Two patients developed recurrences at the primary site following surgery. One patient developed recurrence twice despite gross total excision of tumor in each sitting. Subsequently, this patient remained symptom free for a follow-up period of 1 year. Another patient developed recurrence 2 years following surgery, but he died due to septicemia and aspiration pneumonitis. Therefore definitive surgery could not be performed. Radiotherapy was offered to one of the patients having residual mass post operatively, to render her symptom free for a 4 year follow-up. The remaining two patients have also showed progressive improvement in their symptoms following surgery for 4 years on follow-up. Hydrocephalus was a common feature in all the cases preoperatively, but only one required shunt CSF diversion, because of rapid deterioration in visual equity. In all other cases, hydrocephalus was managed conservatively. Surgery remains the main modality of treatment for CPP, both for primary and recurrent tumors, but radiotherapy may have a role in cases of recurrence, which are quite frequent.

Spectrophotometric determination of sulphacetamide

A new rapid selective spectrophotometric method for the determination of sulphacetamide is described. The drug forms a orange-yellow colored complex with Cerium(IV) in sulfuric acid media which is extracted into ethyl acetate. The complex exhibits a maximum absorbance at 440 nm with a molar absorptivity of 3 x 10(2) 1 mol-1 cm-1. The system obeys Beer's law in the concentration range of 0.07-1.1 mg of sulphacetamide. The various parameters for the optimum extraction conditions are discussed. The method is applied to the determination of sulphacetamide in dosage forms.

Medulloblastomas: clinical profile, treatment techniques and outcome - an institutional experience

The present series reports an audit on the patterns of presentation, radiation treatment techniques, failure pattern and outcome in the 36 patients treated at a single institution. Patients were accrued between October 1991 and September 1999. They underwent total or subtotal resection along with craniospinal irradiation. The dose to the cranium ranged from 30 to 43Gy (median- 36Gy), to the spine from 20 - 36Gy (median- 36Gy) and the posterior fossa boost, which was delivered in 32 cases, ranged from 14 to 24Gy (median -18Gy). Simulator film evaluation was carried out at the time of analysis based on the French Medulloblastoma Group guidelines, which revealed a significant under-dosage in the region of posterior fossa and cribriform plate in 27% and 19% respectively. Adjuvant chemotherapy was administered in 7 patients. Salvage treatment in the form of chemotherapy (5 cases) and re-irradiation (2 cases) were attempted but were ineffective. The overall survival (OS) and progression free survival (PFS) rates were 54% and 40% respectively, with the median being 75 and 29 months respectively. Amongst all the prognostic factors considered, on univariate analysis, duration of symptoms was significant for PFS with a trend towards significance for OS, while extent of debulking had a trend towards significance for PFS. No factor emerged significant on multivariate analysis.

Migraine-like visual hallucinations in occipital lesions of cysticercosis

Four Indian patients with occipital lesions of cysticercosis presented with visual hallucinations. Neuro-ophthalmic and systemic examinations were normal in all cases except for one patient who had a partial homonymous hemianopia. Electroencephalography was normal in all cases. Neuroimaging revealed ring-enhancing lesions in the occipital lobe typical of neurocysticercosis. In endemic regions like India, neurocysticercosis should be suspected in patients presenting with visual hallucinations, even when there are no other clinical findings.

Activity of infusional etoposide, vincristine, and doxorubicin with bolus cyclophosphamide (EPOCH) in relapsed Hodgkin's disease

INTRODUCTION

A phase II study of EPOCH chemotherapy in relapsed Hodgkin's disease was performed in 14 patients in a multicenter community setting. Patients and Methods. A total of 14 patients (9 males and 5 females) were included in the study. Ages ranged from 21-72 with a median age of 33. Eleven out of 14 patients had advanced (stage III or IV) disease, but all patients had good performance status. All 14 patients had received prior chemotherapy with ABVD, MOPP, or MOPP/ABVD hybrid.

RESULTS

A total of 57 cycles of EPOCH were administered during this trial. Patients received a median of four cycles of chemotherapy. An overall response rate of 86% was seen among the 14 patients with one patient achieving a complete response. Following EPOCH chemotherapy, 7 of 12 patients who responded underwent high-dose chemotherapy with stem cell support. Six out of 14 patients are currently alive, and three had no evidence of disease at the time of last follow-up. Toxicity with EPOCH chemotherapy consisted mainly of myelosuppression, and most patients were managed on an outpatient basis.

CONCLUSION

This multicenter community study confirms the activity of EPOCH chemotherapy in the treatment of patients with relapsed Hodgkin's disease.

Anterior retropharyngeal approach to the cervical spine

The anterior retropharyngeal approach (ARPA) accesses anteriorly situated lesions from the clivus to C3, in patients with a short neck, Klippel Feil anomaly or those in whom the C2-3 and C3-4 disc spaces are situated higher in relation to the hyoid bone and the angle of mandible where it is difficult to approach this region using the conventional anterior approach, due to the superomedial obliquity of the trajectory. The ARPA avoids the potentially contaminated oropharyngeal cavity providing for a simultaneous arthrodesis and instrumentation during the primary surgical procedure. Experience of five patients with high cervical extradural compression, who underwent surgery using this approach between 1994 and 1999, is presented. The surgical procedures included excision of ossified posterior longitudinal ligament (n=2); excision of prolapsed disc and osteophytes (n=2); and excision of a vertebral body neoplasm (n=1). Following the procedure, vertebral arthrodesis was achieved using an iliac graft in all the patients. Only one patient with vertebral body neoplasm required an additional anterior cervical plating procedure for stabilisation the construct. The complications included transient respiratory insufficiency and neurological deterioration in two patients; and, pharyngeal fistula and donor site infection in one patient.

Extended frontobasal approach to the skull base

The extended frontobasal approach provides an adequate midline exposure from the anterior cranial fossa to the sphenoclival region. Between November 1991 and August 1999, 13 patients with extensive anterior and anterolateral skull base tumours extending to supra and parasellar regions, cavernous sinus and sphenoclival regions were operated upon using this approach alone (7 patients) or in combination with subtemporal -infratemporal (4 patients) or transfacial (2 patients) approaches. Gross total excision was performed in 8 patients while in 4 patients with malignant tumours and in a patient with extensive skull base fungal granuloma, only partial excision was possible. Basal repair was performed using pedicled pericranium, temporalis muscle or fascia lata. The complications included increase in the cranial nerve paresis, endophthalmitis, facial oedema, CSF leak, frontal haematoma and internal carotid artery injury. This study reviews the operative technique, the indications and the complications of extended frontobasal approach.

Thoracic myelopathy secondary to ossified ligamentum flavum

BACKGROUND

Focal ossification of the ligamentum flavum (OLF) forms one of the rare causes of thoracic myelopathy. The lower thoracic spine is most frequently affected and the patients present with initial posterior column disturbances followed by progressively increasing spastic paraparesis. The pathogenesis of OLF has not been conclusively established.

METHOD

Five patients with thoracic myelopathy due to OLF underwent decompressive laminectomy and excision of the ligamentum flavum. Their MRI delineated a linear or beak like excrescence, uniformly hypo-intense on T1 and T2 weighted images, situated posterior to the thecal sac. A comparison between the preoperative neurological status and the status at follow-up was done using Harsh's myelopathic grading.

FINDING

Decompressive laminectomy followed by the drilling of the OLF and its excision, occasionally along with the adherent outer layer of the dura, resulted in significant improvement in motor weakness and tingling sensations. However, at the last available follow-up, none of the patients had retained their ability to run briskly (grade I) and all of them had residual spasticity.

INTERPRETATION

OLF may significantly contribute to a spatial reduction of the thoracic spinal canal resulting in paraparesis. The T2 weighted sagittal image of the magnetic resonance imaging (MRI) is the modality of choice for screening of the longitudinal extent of the OLF. A rapid neurological improvement occurs following decompressive laminectomy and excision of the OLF. However, the persistence of residual spasticity at follow-up may be due to irreversible changes within the cord by the significant thecal compression and the delay between the onset of initial symptoms and signs and surgical decompression.

Evaluation of leprosy lesions by skin smear cytology in comparison to histopathology

Cytological evaluation of leprosy skin lesion was done to evaluate cytohistological correlation. Twenty five clinically suspected patients of leprosy were evaluated by performing fine needle aspiration (FNA) in nodular lesions and slit skin smear technique in flat lesions to classify across R-J scale. May-Grunwald-Giemsa (MGG) and Ziehl-Neelsen stain were employed on slit skin smears and fine needle aspiration material. Histopathological assessment of slides from same lesion was done. The overall diagnostic accuracy of fine needle aspiration was 76.1% and that of slit skin smear 50%. However, on adequate material diagnostic accuracy of slit skin smear was high, 100% as compared to 81.8% of fine needle aspiration smears. In cases of polar leprosy cytological findings paralleled histopathological diagnosis. Within the constraints of cytological interpretation the cases in borderline unstable spectrum of leprosy can be classified broadly.

A multicenter trial of infusional etoposide, doxorubicin, and vincristine with cyclophosphamide and prednisone (EPOCH) in patients with relapsed non-Hodgkin's lymphoma

A phase II study was performed in a multicenter community setting of EPOCH (etoposide/doxorubicin/vincristine/cyclophosphamide/prednisone) chemotherapy in 93 patients with relapsed non-Hodgkin's lymphoma. Patients included 41 females and 52 males, ranging in age from 31-81 years (median, 63 years). Lymphoma histologies included diffuse large-cell (56), follicular (21), mantle cell (11), peripheral T-cell (3), and small lymphocytic (2) lymphomas. Patients had received a median of two previous chemotherapy combinations (range, 1-9). Most patients had received the drugs in EPOCH with their previous chemotherapy regimens (vincristine 97%, cyclophosphamide 97%, doxorubicin 87%, and etoposide 28%). A total of 350 cycles of EPOCH were administered. EPOCH chemotherapy gave a response rate of 51% in the entire cohort of 93 patients. Among the 83 evaluable patients, a response rate of 57% was observed (24% complete response, 33% partial response). Seven of the 47 responders remain in clinical remission at 3 years after EPOCH chemotherapy alone. Additionally, 11 patients are alive after further salvage chemotherapy (four patients) or bone marrow transplantation (seven patients). Myelosuppression was common, with 36% of all cycles resulting in an absolute neutrophil count nadir < 500/microL. This study confirms the activity of infusional chemotherapy with EPOCH in patients with relapsed non-Hodgkin's lymphoma.

Intracranial infective aneurysms presenting with haemorrhage: an analysis of angiographic findings, management and outcome

AIM

This study is an analysis of angiographic findings in 17 patients with infective aneurysms who presented with intracranial haemorrhage and reviews the management and outcome in the context of the existing literature.

MATERIALS AND METHODS

A retrospective study of infective aneurysms in 17 patients was carried out. Cranial angiography was performed in all patients. The location, size and outline of aneurysms were analysed. Ten patients were managed conservatively and six patients underwent surgery for the ruptured infective aneurysms and were followed up for a period of 35.8 months and 23 months, respectively.

RESULTS

Twenty-two aneurysms were identified (five unruptured) in 17 patients. Twenty aneurysms (90. 9%) were distal in location and two (9.1%) proximal. Sixty percent were in the posterior circulation with 55% in the posterior cerebral artery (PCA) territory, 27.3% in the middle cerebral artery (MCA) territory and 9.1% in the anterior cerebral artery (ACA) territory. Fourteen aneurysms were small (3-5 mm) and eight were medium sized (6-9 mm). 72.7% of aneurysms had irregular outline and 27.3% regular outline. Out of the 10 ruptured aneurysms managed conservatively, eight resolved. One patient died, presumably due to rebleed, and one had infarction due to parent vessel thrombosis. Six aneurysms were surgically managed with good results. Of the five unruptured aneurysms one was surgically managed and the remaining four conservatively managed patients did not bleed during follow-up.

CONCLUSION

Patients with ruptured infective aneurysms fared well with medical management and the outcome in this series is better than that reported in literature. Patients on conservative management, however, need closer monitoring with angiographic follow-up. Active management is required with enlarging or persisting aneurysms.

Comparative study of topical terbinafine and topical ketoconazole in pityriasis versicolor

Fifty patients suffering from pityriasis versicolor were treated with either 2% ketoconazole cream (25 patients) or 1% terbinafine cream (25 patients). Diagnosis was confirmed by microscopic potassium hydroxide (KOH) examination and either of the cream was applied once daily for a duration of 2 weeks. Global assessment was done at the end of treatment with mycological and clinical cure rate of 88% and 96% in ketoconazole and terbinafine treated groups respectively. After a follow up of 3 months the relapse in ketoconazole group was 13.53% and 8.33% in terbinafine group with no side effects.

Multiple eccrine spiradenomas in zosteriform distribution in a child

A 9-year-old boy presented with asymptomatic papulonodular lesions on the left half of the chin of 3-years duration. On examination he had small papular lesions on the left chin varying in size from 1 to 5 mm. An additional lesion on the margin of the lip was 14 mm in diameter. The overlying skin was normal. Lesions were firm, nontender, and fixed to the skin. Histopathologic examination of the biopsy specimen revealed characteristic features of eccrine spiradenoma. A literature search produced reports of 10 cases of linear/zosteriform spiradenoma. Of these, five were in children or adolescents. We report this patient because of the rare occurrence of this presentation.

Extradural meningioma en-plaque of the cervical cord

A rare case of cervical extradural en-plaque meningothelial meningioma is reported. The magnetic resonance imaging revealed an extradural sheet of tumor encasing the cervical cord from anterior, posterior and right lateral aspects and emerging from the right C3-4 intervertebral foramina. Though a differential diagnosis of lymphoma and tubercular granulation tissue were considered, its isointense intensity patterns on T1 and T2 weighted images and the intratumoral calcification on intrathecal contrast computed tomographic scan suggested a meningioma. At surgery, the lesion was fibrous, avascular and densely adherent to the dura. The radiological features and management options of the lesion are discussed.

C1-C2 rotary subluxation following posterior stabilization for congenital atlantoaxial dislocation

The authors report a rare complication of C1-C2 rotary subluxation in two children following posterior stabilization for congenital atlantoaxial dislocation (AAD). A patient, with mobile AAD, underwent Brook's C1-C2 fusion while the other, with fixed AAD, underwent transoral decompression followed by Jain's occipitocervical fusion. A pre-existing ligamentous laxity associated with an asymmetrical wire tightening or slippage of the wires due to rotation of the neck in the former, and the drilling of the C1-C2 lateral joints during the transoral procedure in the latter, could have contributed to the rotary subluxation. Both patients presented with persistent torticollis due to fusion in an asymmetrical position with dislocated facet joints. Rotary C1-C2 subluxation, when coexisting with anterior dislocation, has the potential to cause severe and occasionally fatal cord compression. Well defined criteria to diagnose this entity by conventional radiology exist, however, due to the overlap of anatomy, the condition is often overlooked. In the present study, three dimensional reconstruction images using helical computerized tomography were very useful in delineating the subluxation and in planning its surgical reduction and arthrodesis.

Study of diffuse alopecia in females

One hundred female patients, in the age range of 14-60 years suffering from diffuse hair loss were studied for pattern of aiopecia and probable causes. Pattern of hair loss was of telogen effluvium in 92% patients, androgenetic alopecia in 7% and anagen defluvium in 1%. The probable causes of diffuse alopecia were found to be psychological stress in 30%, fever in 33%, abortion and delivery in 21%, trauma and surgical operation in 13%, and hypothyroidism in 10%. In 57% patients more than two fac-tors, while in 6% no probable cause could be found on the basis of history. Routine laboratory investiga-tions revealed Hb level less than 12gm% in 96% patients, hypochromic picture on PBF examination in 57% patients, GIT parasites in 13% patients on stool examination, T 3 value less than 70 p gm/dl in 7% and TSH more than 7IU in 8 % cases. Mircoscopic examination of hairs in all the cases showed (telogen) club root except in one case which showed broken and tapered root end (anagen).

Subcutaneous cysticercosis involving the eyelid: sonographic diagnosis

A 25-year-old man and a 14-year-old boy presented with neurocutaneous cysticercosis involving the eyelid. Both patients had hundreds of scattered subcutaneous cysticerci. They were arranged in clusters over the sternocleidomastoid muscle in the neck. Such clustering of cysticerci is highly suggestive of central nervous system (CNS) involvement, as both the sternocleidomastoid muscle and the CNS are supplied by the carotid artery and cysticerci travel via the hematogenous route. We used ultrasonography to diagnose subcutaneous cysticercosis, which showed characteristic low reflective cysts and high reflective scolices inside. Although subcutaneous cysticerci are inconsequential, their verification is important in the diagnosis of more severe CNS involvement. They may be confused with other painless swellings such as lymphadenopathies, neurofibromas, and epidermoid cysts.

Suction blister epidermal grafting versus punch skin grafting in recalcitrant and stable vitiligo

BACKGROUND

Among various surgical therapies for replenishment of melanocytes in recalcitrant and stable vitiligo, punch skin grafting (PSG) and suction blister epidermal grafting (SBEG) are the simplest ones. Literature is lacking on a comparison of both.

OBJECTIVE

We compared the results of both techniques in small patches of vitiligo.

METHODS

Fifty stable vitiligo (focal, segmental, and generalized) patients were selected for study. One patient was lost to follow-up and excluded. PSG was done in 48 patches of 25 patients and SBEG was done in 38 patches of 24 patients. All patients were kept on psoralen ultraviolet-A (PUVA)/psoralen sunrays (PUVASOL). Results were evaluated after a follow-up of 4-7 months.

RESULTS

Thirty-two (67%) patches of the PSG group and 31 (82%) patches of the SBEG group showed greater than 75% pigmentation. The difference in both groups was not statistically significant. Cobblestone appearance (23%) over the recipient area (RA) and superficial scarring of the donor area (DA) (100%) were seen in PSG. No serious complications were seen in both groups.

CONCLUSION

Both techniques are simple and effective, however, SBEG gives cosmetically better and rapid results.

Transoral decompression for craniovertebral osseous anomalies: perioperative management dilemmas

The surgical outcome of 74 patients, who underwent transoral decompression (TOD) for ventral irreducible craniovertebral junction anomalies between January 1989 to September 1997, was studied to evaluate the perioperative complications and problems encountered. The indications for TOD included irreducible atlantoaxial dislocation (n=24), basilar invagination (n=16), and a combination of both (n=35). Following TOD, occipitocervical stabilization using Jain's technique was carried out in 50 (67.5%) and atlantoaxial fusion using Brooks' construct in 18 (24.3%) patients. The pre- and postoperative radiology was compared to assess the adequacy of decompression and stability. The major morbidity included pharyngeal wound sepsis leading to dehiscence (20.3%) and haemorrhage (4%), valopharyngeal insufficiency (8.1%), CSF leak (6.7%) and inadequate decompression (6.7%). Neurological deterioration occurred transiently in 17 (22.9%) and was sustained in 7 (9.4%) patients. The mortality in six cases was due to operative trauma, exanguination from pharyngeal wound (one each), postoperative instability and inability to be weaned off from the ventilator (two each). Of the 47 (63.5%) patients available at follow up ranging from 3 months to 2 years, 26 (55.3%) showed improvement from their preoperative status while 14 (29.8%) demonstrated stabilization of their neurological deficits. Seven (14.9%) of them deteriorated. Though TOD is logical and effective in relieving ventral compression due to craniovertebral junction anomalies, it carries the formidable risks of instability, incomplete decompression, neurological deterioration, CSF leak, infection and palatopharyngeal dysfunction.

Thermodynamic ionization constants of antihypertensive drugs

The thermodynamic ionization constants (pKa) of indapamide, clonidine and methyldopa have been determined at 25 degrees C and 35 degrees C by pH titration technique. The pKa varies linearly with mole fraction of dioxane. The thermodynamic parameters have been calculated.

Extreme lateral transcondylar approach to the skull base

In this study, the authors present their experience of using extreme later transcondylar approach (ELTC) for treating 7 patients with lesions in the anterolateral foramen magnum, upper cervical spine and cerebellopontine angle reaching upto jugular foramen. The tumours included meningiomas, neurofibromas (2 cases each), chondrosarcoma, epidermoid and aneurysmal bone cyst (one case each). The approach was used alone, in combination with retrolabyrinthine presigmoid approach in a patient with lower cranial nerve neurofibroma extending extracranially through the jugular foramen, or in combination with partial C1-C3 laminectomy in two patients with meningiomas situated anterolateral to the cord from the foramen magnum to C3. In two patients with extradural vertebral artery (VA) entrapment by a chondrosarcoma and aneurysmal bone cyst respectively, the vertebral artery was ligated distal to the tumour. The tumours were totally excised in five cases and partially in two. There was no preoperative mortality. The major complications included cerebrospinal fluid leak from the wound (3 cases) and increase in lower cranial nerve paresis (2 cases). At follow up, ranging from 6 months to 2 years, 5 patients showed no tumour recurrence. There was improvement in neurological status. One patient, with a partially excised aneurysmal bone cyst, showed no added deficits or increase in the tumour size. However, there was a massive regrowth in the patient with chondrosarcoma after 6 months. This technique provided a wide surgical exposure with direct visualization of the tumour-anterior cord interface, early proximal control of the VA and preservation of lower cranial nerves.

Choroid plexus papilloma of cerebellopontine angle with extension to foramen magnum

A case of choroid plexus papilloma resembling meningioma of cerebellopontine (CP) angle with its extension to foramen magnum is presented. Occurrence of this tumour in CP angle is very rare. Its extension towards foramen magnum is further rare. It was a real diagnostic enigma preoperatively as the tumour was resembling meningioma upto some extent on radiological study. Retromastoid craniectomy with microsurgical excision of tumour and its extension was achieved in toto. Tumour was attached to few rootlets of lower cranial nerves which were preserved. Attachment of the tumour with lower cranial nerves again caused diagnostic confusion with neurofibroma intraoperatively.

Third ventricle choroid plexus papilloma with head tremors

A rare case of third ventricular choroid plexus papilloma is reported. A two year male child presented with clinical features of raised intracranial pressure, meningismus, gait ataxia and abnormal head tremors. Abnormal head tremor is an extremely uncommon presenting feature of a choroid plexus papilloma of third ventricle.

Solitary mastocytoma in an adult

A 24-year old female developed late onset solitary mastocytoma on the left forearm. She complained of intense pruritus off and on which was not associated with flushing of face and blister formation over the nodule. Darier's sign was positive. Excisional biopsy was done and histopathology confirmed the diagnosis.

A Software programme for data analysis of cerebral aneurysms

Research by traditional methods of collection of data from case files, proformas, registers and master charts is laborious and cumbersome process. Case files in the hospital record section are often not easily accessible and can get lost. Moreover manually recorded and analysed data occupies lot of space. This entire tedious business is highly simplified by using computer software for record keeping and its analysis. We describe the development of a comprehensive, user friendly software programme for neurosurgeons using FoxPro to analyse data of cerebral aneurysm patients. Data entry is done with the help of prompted picklist instead of codes, the selection of which is tapping a key without the need to type it. This entered data is automatically converted into a computer database which generates more than 75 tables and graphs of predetermined nature and covers most of the parameters a neurosurgeon would be interested in. This coded database also generates a discharge summary in a flowing text. The prototype of programme has been used in our first hundred patients of cerebral aneurysm and debugged while analysing the next fifty.

Keratoderma hereditaria mutilans (vohwinkel's syndrome)

We report two cases of Vohwinkel's syndrome in son and mother presenting with a progressive palmoplantar keratoderma with 'honeycomb' appearance associated with constricting bands encircling digits of hands and feet along with keratotic plaques on dorsum of hands and feet. Both had associated sensorineural deafness.

Serum lipid profile in leprosy

Serum lipids and lipoproteins were assessed in 40 patients of leprosy and 20 healthy controls (age & sex matched). The leprosy cases included 20 cases each of paucibacillary and multibacillary leprosy.

Corpectomy for multi-level cervical spondylosis and ossification of the posterior longitudinal ligament

The choice of a surgical approach for multi-level cervical spondylotic myelopathy (CSM) and ossification of the posterior longitudinal ligament (OPLL) is still a controversial issue. While most of the surgeons are still performing decompression by laminectomy, some are doing multi-level anterior decompression. Few neurosurgeons are performing decompression by corpectomy. We have treated 26 patients by median cervical corpectomy during the last 4 years. These patients were followed up for a mean period of 25 months. Twenty one (80%) patients had a good outcome, 2 patients remained unchanged and 3 expired. Review of the literature and our experience indicates that patients with CSM and OPLL should be operated by median cervical corpectomy (anterior approach).

Adenosine deaminase activity in serum and lymphocytes of multibacillary leprosy patients

Adenosine deaminase (ADA) activity was measured in serum and lymphocytes of 25 untreated patients with multibacillary leprosy. Both serum and lymphocyte ADA levels were significantly high in multibacillary leprosy patients compared to healthy controls. The results obtained did not establish any significant relationship between ADA activity and the type of leprosy.

Growth hormone-producing pituitary tumours: clinical profile and results of surgery

BACKGROUND

Growth hormone-producing pituitary tumours present with a wide variety of manifestations. The optimum diagnostic work up, management and follow up of such patients is complex and involves a multidisciplinary approach. There is paucity of data from India with regard to the clinical presentation and results of surgery for growth hormone-producing tumours.

METHODS

We studied the first 50 patients presenting during 1989-94 with growth hormone-producing pituitary tumours to our centre. The work up included detailed endocrine and radiological assessment. The surgical outcome was analysed for 35 patients who were operated (trans-sphenoidal 29, transcranial 6) at our centre.

RESULTS

All the patients had macroadenomas [mean (SD) diameter 3.12 (0.87) cm]. Seventy-five per cent of the patients had supra- and/or parasellar extension and 57% had visual field defects. Tumour size correlated with the preoperative basal (r = 0.57) and glucose-suppressed (r = 0.54) growth hormone levels. Thirty-three of the 35 patients operated at our centre (trans-sphenoidal 28, transcranial 5) were available for follow up (median duration 34 months). After trans-sphenoidal surgery alone, 12 of the 28 (43%) patients had normalization of growth hormone levels (post-glucose growth hormone < 5 ng/ml), and 9 of 11 (82%) showed improvement in visual fields.

CONCLUSION

In India, growth hormone-producing pituitary tumours are usually large in size. The growth hormone levels correlate with the size of the tumour. These tumours can be effectively treated by trans-sphenoidal or transcranial surgery.

Giant cell tumor of sphenoid-diverse presentation: report of two cases

Two rare cases of giant cell tumors of the sphenoid bone are presented. We discuss their imaging, unpredictable biological behavior and management together with a review of the pertinent literature.

A double-blind comparison of 2% ketoconazole and 1% clotrimazole in the treatment of pityriasis versicolor

Forty adult patients of pityriasis versicolor were treated with either topical 2% ketoconazole cream (20 patients) or topical 1% clotrimazole cream (20 patients). In global assessment of treatment after 2 weeks, 18 (90%) out of 20 patients treated with ketoconazole cream were cured while 2 cases had considerable residual lesions. In clotrimazole treated group, 17 (85%) out of 20 patients were cured and 3 still had considerable lesions. No significant difference was observed in response rates in the two groups. No side effects were reported in either groups.

Immunoglobulin M immunoblot for diagnosis of Borrelia burgdorferi infection in patients with acute facial palsy

We used immunoblotting to improve the specificity of the serologic diagnosis of Lyme borreliosis in cases of acute facial palsy. Twelve of 15 patients (80%) with suspected Lyme borreliosis, versus 0 of 10 controls, were positive by immunoglobulin M immunoblotting of acute-phase sera and 3 were negative, including 2 with borderline enzyme immunoassay results. Immunoglobulin M immunoblotting is a useful test to confirm Borrelia burgdorferi infection in patients with acute facial palsy and a positive enzyme immunoassay result.