A modern minimally invasive transcallosal approach to the third ventricle. A personal experience of 30 patients

INTRODUCTION

Expansive processes around the third ventricle have always been a major neurosurgical challenge. Despite all the technological and scientific progress recorded over the last few years, third ventricle tumors are still a very difficult pathology to approach due to their formidable complexity.Treating such a tumor demands a good knowledge of local anatomy, pathophysiology, pathology and a good capacity to integrate all the data gathered from the patient prior to and during surgery. Last but not least, the correct means to approach such a tumor involves using modern neuronavigation technology which might be too expensive to access in certain clinics (1,2).

OBJECTIVE

This article presents the personal experience of the authors, gathered while using a novel surgical approach,configured to maximize the success rate of interventions for tumors within the third ventricle, without using neuronavigation technology.

MATERIALS AND METHODS

The authors have developed a study of neuroanatomy using 30 adult human brains, without any pathological lesions, harvested during routine autopsies and analysed using a a standard protocol (Protocol of the Ludwig-Maximilians University Clinic of Neurosurgery, Laboratory of Microanatomy - Munich, Germany). The authors assessed a series of anatomic elements which were later used as landmarks to build the neurosurgical operative field. After completing the anatomic study the authors moved on to record morphometric data for 30 volunteers. The authors used sagittal T1 weighted images. The volunteers were males and females, all adults, with the mean age of 45.3 years. (The age interval: 21-83 years, sex distribution: 17 males and 13 females). The images were digitally enhanced and the specific targets were outlined using Corel Draw, thus allowing for a systematic identification of contours and landmarks. Each contour was recorded and saved as a sequence of dots. The next stage of the study, after having studied all the data recorded, consisted of establishing the appropriate transcallosal surgical corridor (transforaminal or inter forniceal) for each of the 30 patients (not to be mistaken with the 30 volunteers)who were admitted for third ventricle tumors and who were included in this study. After having performed surgery for there section of the above mentioned third ventricle tumors, the authors observed pre- and postoperative clinical data which were corroborated with the neuropsychological examination which was also performed prior to and after surgery.

CONCLUSIONS

The results obtained through observation and anatomical measurements have proven to be highly valuable in determining a standard access corridor through the corpuscallosum. The data gathered and the patient's MRI exam images helped obtain an optimal surgical corridor of the third ventricle. In what regards the surgical act in 23 cases (77%) the authors managed to achieve a complete resection of the tumor.In 6 cases (20%) the authors managed a subtotal resection of the tumors. In a single case the authors performed only a biopsy. A number of 24 patients (80%) achieved an excellent outcome (Glasgow Outcome Scale - GOS V). Minor deficits were recorded in 5 patients (17%) (disabled but independent)(GOS IV) No cases were recorded with serious impairment(GOS III) or vegetative state (GOS II). One patient with anaplastic glioma died 4 months after surgery after an initial favorable evolution. The tumor had spread to the hypothalamus. A single postoperative complication was linked to the surgical approach in a 73-year-old female patient who suffered a venous infarction due to a venous thrombosis in atributary vein of the superior sagittal sinus in the access area.The patient, after a slow recovery managed to improve her condition reaching GOS IV. There were no other complications connected to the surgical act.

Spin pseudogap in Ni-doped SrCuO2

The S=1/2 spin chain material SrCuO2 doped with 1% S=1 Ni impurities is studied by inelastic neutron scattering. At low temperatures, the spectrum shows a pseudogap Δ≈8  meV, absent in the parent compound, and not related to any structural phase transition. The pseudogap is shown to be a generic feature of quantum spin chains with dilute defects. A simple model based on this idea quantitatively accounts for the experimental data measured in the temperature range from 2 to 300 K, and allows us to represent the momentum-integrated dynamic structure factor in a universal scaling form.

Outcomes of Category III DOTS treatment in immunocompetent patients with tuberculosis pleural effusion

OBJECTIVES

To study the efficacy and safety of Category III DOTS treatment (intermittent thrice-weekly rifampicin [RMP], isoniazid [INH] and pyrazinamide for 2 months, followed by RMP and INH for 4 months) under India's Revised National Tuberculosis Control Programme in patients with uncomplicated small unilateral pleural effusion (<1500 ml).

DESIGN

This prospective, multicentre, observational study recruited 351 patients between 2006 and 2010. Patients were regularly followed up clinically as well as with ultrasound examination of the chest.

RESULTS

Successful outcome (clinical response with complete resolution on ultrasound examination at 6 months) was seen in 274 patients (78.1%). Efficacy was 88.9% (excluding defaulters), and 94% among those completing follow-up as per protocol. None of the patients received corticosteroids. Other outcomes included treatment extension (n = 26, 7.4%), default (n = 43, 12.2%), treatment failure (n = 3, 0.9%) and death (n = 3, 0.9%). Seventy-nine mild/moderate adverse events and one treatment-related serious adverse event were noted; one patient developed recurrent drug-induced hepatotoxicity. Two patients (0.7%) had relapse/re-infection at 24 months follow-up.

CONCLUSION

Intermittent thrice-weekly treatment for 6 months with three drugs in the intensive phase is effective and safe for unilateral small pleural effusion in immunocompetent patients. Although Category III no longer exists in the programme, the results are reassuring for intermittent treatment in extra-pulmonary TB under programme conditions.

Tuberculous lymphadenopathy: a multicentre operational study of 6-month thrice weekly directly observed treatment

SETTING

Eight operational locations for the Revised National Tuberculosis Control Programme in six Indian states.

OBJECTIVE

To assess the 6-month efficacy of an intermittent thrice-weekly directly observed treatment (DOT) regimen for tuberculous peripheral adenopathy and the need for prolongation of treatment to 9 months for non-resolution of lymphadenopathy.

DESIGN

Patients aged >5 years with tuberculous lymphadenopathy were included in the study. Patients were evaluated for resolution at repeat visits following treatment. Those with poor resolution at 6 months were randomised to extended treatment up to 9 months or observation without additional treatment.

RESULTS

Resolution of lymphadenopathy was observed at the end of 6 months in 517/551 (93.8%) patients. There was a significant difference in response among patients with and those without the presence of systemic symptoms. There was no association between treatment response and number, size, site, consistency and matting of lymphadenopathy. No differences in response were seen in the remaining 34 patients with or without extended treatment.

CONCLUSION

The operational efficacy of 6-month thrice-weekly DOT for peripheral tubercular lymphadenopathy was satisfactory. There was no evidence of additional benefits of prolonging treatment to 9 months.

Risk and outcome of multidrug-resistant tuberculosis: vitamin D receptor polymorphisms and serum 25(OH)D

SETTING

All India Institute of Medical Sciences and Rajan Babu Institute of Pulmonary Medicine and Tuberculosis, New Delhi, India.

OBJECTIVE

To investigate the association of vitamin D receptor (VDR) polymorphisms and serum 25(OH)D with susceptibility to, and response to treatment of, multidrug-resistant tuberculosis (MDR-TB) in comparison with drug-susceptible pulmonary TB (DS-PTB) and healthy controls.

DESIGN

Cross-sectional study.

METHODS

A total of 897 participants from northern India were consecutively enrolled into three groups (MDR-TB 354, DS-PTB 338, controls 205). Genotypic and allelic frequencies of FokI, BsmI and TaqI VDR polymorphisms, and serum 25(OH)D, calcium and intact parathyroid hormone were measured in all participants. In those with active TB, disease severity, time to sputum smear and culture conversion were correlated with VDR genotype and biochemical parameters.

RESULTS

FokI Ff genotype and TaqI t allele correlated positively with MDR-TB; Ff genotype and f allele of FokI frequency were higher in both TB groups. BsmI Bb genotype correlated inversely with MDR-TB. Serum 25(OH)D concentrations were significantly lowest in MDR-TB, correlating inversely with time to sputum smear conversion.

CONCLUSIONS

VDR gene polymorphisms and hypovitaminosis D may predispose to MDR-TB. Lower serum 25(OH)D may increase time to MDR-TB sputum smear negativity.

Impact of changes in extracellular matrix in the lumbar degenerative disc

The complexity of the clinical, biochemical, hystochemical and immunologic aspects of the intervertebral disk, along with its molecular biology, justifies the object of our study on the extracellular matrix modifications in lumbar disk hernias and their impact on patient quality of life.

MATERIAL AND METHOD

The research lot was composed of 50 patients, aged between 18 and 73, who have undergone lumbar disk hernia surgery. MMP-9 (metalloproteinase-9) and TIMP-1 (tissue inhibitor of matrix metalloprotease 1) have been dosed in order to study the modifications on extracellular disk matrix, and quality of life assessment was carried out both in pre-operatory and post-operatory periods.

CONCLUSIONS

Patients may prevent the appearance of degenerative processes of the intervertebral disk with care and responsibility by controlling their weight, avoiding intense physical activities and ceasing to smoke.

Deltamethrin Increases Candida albicans infection susceptibility in mice

Deltamethrin, an alpha-cyano type II synthetic pyrethroid insecticide, is used to control a wide range of insects on a variety of crops and vectors of diseases. Deltamethrin has been previously reported for its immunotoxic effects and therefore its exposure may affect the host resistance to infection and tumour challenge. Effect of exposure of deltamethrin on host resistance to Candida albicans infection was examined in Swiss albino mice. The objective of this study was to investigate the modulatory action of deltamethrin in C. albicans infected mice. The dose of deltamethrin was initially tested and selected from our previous study (18 mg/kg). Percentage of infection in deltamethrin treated animals increased faster when compared to that of the controls. Deltamethrin exposure along with C. albicans infection caused alteration of humoral immune response. The number of colony forming unit in liver and spleen were also found to be significantly increased in the treated group. The results from our present study suggest that deltamethrin exhibits an immunosuppressive effect and has a negative impact on host resistance to C. albicans infection.

Pain and paraesthesia produced by silicone ring and pneumatic tourniquets

Twenty volunteers were recruited to compare a novel, silicone ring tourniquet (the Hemaclear® tourniquet) with a pneumatic tourniquet. After application of the tourniquets, the pain and paraesthesia experienced by the participants was scored at 1 minute, 5 minutes, and 10 minutes. This was repeated with the tourniquets on the forearm. On the upper arm, the silicone ring tourniquet was associated with a significantly lower pain score than the pneumatic tourniquet. The incidence of paraesthesia was also lower with the silicone ring tourniquet. When applied to the forearm, there was no statistically significant difference in pain scores between the two types of tourniquets. However the incidence of paraesthesia was again lower with the silicone ring tourniquet.