Management and outcome of locally advanced oral squamous cell carcinoma

Management of locally advanced OSCC is multimodal. No single therapy has been proved to be efficacious. However there is a trend towards surgical intervention in operable disease. In this review we appraise the various therapies used for the management of locally advanced OSCC. We review the literature with regards to the various treatment options for locally advanced OSCC. We categorically divided the manuscript into resectable, unresectable and technically unresectable disease. Surgery is the ideal treatment modality for resectable disease. For unresectable disease concurrent chemoradiation appears to improve survival compared to radiotherapy alone. Induction therapy might downstage tumors in the unresectable category. Targeted and Immunotherapy is reserved for recurrent, metastatic or platinum refractory OSCC. Management of locally advanced OSCC is multimodal with surgery playing the primary role. In the event where the tumor is in operable concurrent chemoradiotherapy is regarded as the best treatment modality. Induction chemotherapy currently cannot be recommended for resectable or even unresectable oral squamous cell carcinomas. However for technically unresectable disease it might play a role in improving respectability but it depends on the response of the tumor. Targeted therapy and immunotherapy is currently used for recurrent, metastatic and/or platinum refractory Head and Neck cancers. Currently it is not recommended for initial management of locally advanced disease.

Indian Laws during COVID-19 Pandemic: Implications to Health and Management

Introduction: 2019 corona virus disease (COVID-19), a respiratory disease caused by a new corona virus (SARS corona virus 2, also known as novel corona virus) in China, has spread and attracted worldwide attention. The WHO declared the outbreak of COVID-19 a global public health emergency on January 30, 2020. Following the 2002 corona virus (SARS-Corona Virus) and the 2012 MERS Corona Virus, the virus SARS corona is the third most infectious disease and the largest corona virus that caused human outbreaks in the 20th century. Aim: To assess the Indians law that affects or supports the Indian citizen with present scenario of Pandemic. Conclusion: Coronavirus has called for a mixed response in India. The answer includes a host of regulations, guidelines, services, and administrative structures, as well as public and government warnings. As the demands of government action grow, the Passivence Sicknesses Act has become a topic of discussion. Instead of establishing a comprehensive health care system, the Pestilence Infections Act allows states to take special measures in response to serious infectious diseases. The law gives the public a broad mandate to participate in oppressive actions against citizens within this limited framework.

Spontaneous Spinal Intramedullary Hematoma in an Infant: A Rare Entity and a Diagnostic Challenge

Introduction

Spontaneous spinal intramedullary hematoma is a rare cause of acute paraplegia in adults and is extremely uncommon in children. Very few cases with no apparent etiology (such as trauma, vascular lesions) have been reported in adults. We did not find any apparent cause for the hematoma in our patient and to the best of our knowledge, this is first case reported in infants.

Case Report

We present the case of a 6-month-old female child admitted with acute-onset paraplegia, bladder bowel involvement, and no history of trauma or bleeding diathesis. The MRI showed an intramedullary mass extending from the D11-L1 level. The mass was excised and histopathology revealed it to be an organizing hematoma.

Conclusion

Our case highlights that though it is a rare entity, there is a need for more awareness when dealing with children with sudden paraplegia, acute retention of urine, or neurological deficit. Early diagnosis and prompt surgery are crucial to achieve the best neurological outcome.

Paediatric brain abscesses in tribal region of India

Introduction: Brain parenchymal abscesses are relatively infrequent but potentially serious infections in the paediatric population. Surgical intervention in addition to a prolonged administration of antibiotics is generally appropriate management. Aims and objective: We performed this study to assess the clinical profile, aetiology and outcome of paediatric brain abscess which are treated surgically only by aspiration in the tribal region of Rajasthan. Material and method: A single-centre retrospective study was conducted over a 5 year period (2014–2019) in the department of neurosurgery in RNT medical college, Udaipur, Rajasthan. We treated approx 60 patients of which 25 patients treated conservatively and 5 patient treated by craniotomy and abscess excision. So only 30 patient included in our study in which abscess treated by aspiration only. Patients<18 years of age with a confirmed intra-parenchymal abscess were included. Patient records were reviewed for abscess location, microbiology results, Clinical features, Surgical intervention, and outcome using the Glasgow Outcome Score at 3 months. Result: 11 patients had an abscess in the temporal lobe and Streptococcus was the most common causative micro-organism (n¼15). 25 patients (80%) had an identifiable source which included: ENT infections, congenital cardiac malformations, recent dental surgery and meningitis. The most common symptom is fever f/b headache, seizure and vomiting. But despite previous studies seizure (10/30) presentation is comparatively more. All 30 patients underwent aspiration. Conclusion: In tribal regions of India ENT infections are a more common source of brain abscess because of poor hygiene and illiteracy and their ignorance of ENT infections and also not taking seriously to fever, headache and other health issues. But at present, there are also decreasing trends of brain abscess by ENT infections and rising trends by congenital heart disease which is a good sign that the health and educational infrastructure is strengthening in the tribal region also.

Arrested Hydrocephalus Complicated by Growing Skull Fracture - A Case Report with Review of Literature

Growing skull fracture (GSF) is an extremely uncommon entity and accounts for less than 1% of the skull fractures. This type of fracture is commonly seen in children of less than 3 year of age and two third of them occur in less than one year of age. Occurrence of GSF is higher in infancy and early childhood because of rapid growth of brain and skull take place in initial two year of the life. Dural tear is most common etiological factor that leads to growing skull fracture. Growing skull fracture with arrested hydrocephalus is a rare association and has been described only once in literature. We hereby, are reporting a case of one year child presented with gradual progressive head enlargement with progressive subgaleal swelling over left parietal region. patient sustained head injury 4 month back due to fall from bed. After all relevant radiological examinations, cyst excision and water tight dura closure was done. Patient improved and till last follow up there was not any recurrence of cyst.

Traumatic isolated intracerebellar haematoma without any supratentorial lesion

Purpose. Pure isolated cerebellar haematoma of traumatic aetiology, without associated posterior fossa sub- or epidural haematomas and without supratentorial bleed is a rare entity. We conducted this retrospective study to analyze the management strategy of isolated traumatic intracerebellar haematoma without supratentorial lesion in our institute. Methods. We retrospectively reviewed records of more than 15000 head injury patients in our department of neurosurgery between January 2014 and November 2019. In this isolated intracerebellar hematoma patients are  60. Patients were divided into two groups assessed by the GCS score at the time of presentation – Group A (GCS>13) Group B (GCS lesser than or equal to 13). Group A  treated conservatively and  B  surgically. Group A subdivided according to the size of hematoma into1st  (>3cm ) and 2nd  (<3 cm ). Group B subdivided according to GCS into 1st ( <8 ) and 2nd ( 8-13). Results. Most Group B, subgroup 1st ( GCS<8)  patients found to be associated with poorer outcome ( 60 %) and subgroup 2nd  ( GCS 8-13) had only 10 %. Group A subgroup 1st ( > 3 cm hematoma) has associated with poor outcome ( 28.57%)  and Subgroup 2nd  ( < 3 cm ) has  4.34% . GCS score at the time of admission, hematoma size, hematoma location, the timing of surgery were important factors for outcome. Conclusion. We concluded that hematoma size is > 3 cm and GCS > 8 patient should operate within 12 hr. Patient of GCS < 8  results of surgery are poor( 60%.) .If the size of hematoma < 3 cm, lateral hematoma and GCS >13 should be treated conservatively.  The factors which may be associated with the poor outcome are Low GCS score at the time of admission(<8), the large size of hematoma (>3cm), median location and delay time of surgery(>12hr).

Endoscopic Third Ventriculostomy for Hydrocephalus in Infants: A Single-center Experience

Introduction:

Hydrocephalus remains one of the more common pathologies managed in pediatric neurosurgery. Endoscopic third ventriculostomy (ETV) has become the procedure of choice for the treatment of hydrocephalus due to aqueductal stenosis with high success rate. It has an advantage over ventriculoperitoneal (VP) shunting, as it enables patients to remain device free.

Objective:

The purpose of this study is to assess the role of ETV in the treatment of hydrocephalus in children under 1 year of age, including preterm low birth weight infants.

Materials and Methods:

A prospective study of 30 infants undergoing ETV in our institution between January 2014 and December 2018 was carried out. There were 25 cases of congenital hydrocephalus with aqueductal stenosis, two cases of Dandy–Walker cyst, two cases of cerebellopontine angle arachnoid cyst, and one case of posttubercular meningitis. ETV success score was calculated preoperatively to evaluate the percentage of success of ETV.

Results:

The overall success rate was 76.66% (23), with highest success rate of 84% in aqueductal stenosis. The mean age was 6.75 months (range: 1.5–12 months). Five infants were born preterm, four of them required a permanent VP shunt. There were two cases of intraoperative bleeding, four cases of cerebrospinal fluid leak from the wound, and one case of meningitis.

Conclusion:

ETV can be considered a safe and effective modality for the initial treatment of hydrocephalus in full-term normal birth weight infants, while the success of ETV in preterm low birth weight infants need further study of maturity at birth and birth weight as the determinant factors for the success of ETV in this special group.

Soft & Hard Tissue Assessment around Immediate & Delayed Implants: A Clinico-Radiographical Study

The aim of the modern dentistry is to provide the predictable treatment in short duration. Replacement of missing teeth in shorter duration helps in fulfilling patient's aesthetics and functional demands. Endosseous dental implants are predictable method for replacing missing dentition. The evolution in implant surgical techniques is focused on decreasing treatment duration, e.g. implants can be placed in fresh extraction socket. Therefore, this non-randomized clinical controlled study was designed to determine that whether the treatment outcomes obtained by short treatment duration (immediate implant) are comparable with conventional treatment options (delayed implant) by evaluating the peri-implant soft and hard tissue level, clinically and radiographically {by Cone beam computed tommography (CBCT)}. Total of 30 implants were placed in 13 patients, according to Type 1 ITI protocol (Group 1; 15 implants) and Type 4 ITI protocol (Group 2; 15 implants). Implants in each group were loaded with definitive restoration after 3 months of placement. Hard tissue parameters (marginal bone width and height and probing depth) and soft tissue parameters (width of keratinised gingiva and papillary index) were evaluated at baseline, 3 months post implant insertion and 3 months post prosthetic loading. The results showed statistically significant reduction in width of marginal bone in delayed implants as compared to immediate implants. In contrast, significant reduction in marginal bone height and width of keratinised gingiva was evident in immediate implants. Significant reduction in pocket depth (after 2nd stage surgery and 3 months post prosthetic loading) was noted around delayed implants (p<0.05). Moreover, esthetic results showed regeneration of interproximal papillae in both the groups till the end of study period. This study was concluded that both the groups showed similar results but in some aspects delayed implants was superior to immediate implants. Careful evaluation of implant placement sites before implant installation promotes optimal implant esthetics and survival outcomes.

Clinical spectrum of paediatric head injury

Introduction: Traumatic Brain injury is considered as a major health problem which causes frequent deaths and disabilities in paediatric population with special concern to tribal regions of developing countries like India where etiology of traumatic brain injury in the paediatric population fall from height dominant over the road traffic accident as a major. Aim and objective: The aim is to analyse the epidemiology, mechanism, clinical presentation, severity and outcome of paediatric head injury in the tribal region of northern India that could help to make preventive policies to improve their care. Material methods: It is a prospective observational study of 345 children of up to 18 years of age admitted under Department of Neurosurgery from October 2017 to April 2019. Results: The study population comprised of 345 paediatric patients. Mean age was 9.25 years.36.81% patients were in 1-6-year age group and male to female ratio was 2.45. The most common cause for trauma was fall from height in 179(52%) cases followed by RTA in 141(41%) cases. The most common radiological finding was depressed skull fractures in 97(50%) cases. There was 35% mortality in severe head injury patients. Conclusion: This study through some light on the different scenario of head injury in Tribal regions of Developing country and will help to formulate effective strategies for prevention and better care of the patients.

Clinical spectrum of paediatric head injury. A prospective study from tribal region

Introduction: Traumatic brain injury is considered as a major health problem which causes frequent deaths and disabilities in the paediatric population with special concern to tribal regions of developing countries like India where aetiology of traumatic brain injury in the paediatric population fall from height dominant over the road traffic accident as a major. Aim & Objective: The aim is to analyse the epidemiology, mechanism, clinical presentation, severity and outcome of paediatric head injury in the tribal region of northern India that could help to make preventive policies to improve their care. Material Methods: It is a prospective observational study of 345 children of up to 18 years of age admitted under Department of Neurosurgery from October 2017 to April 2019. Results: The study population comprised of 345 paediatric patients. Mean age was 9.25 years.36.81% patients were in 1-6-year age group and male to female ratio was 2.45. The most common cause for trauma was fall from height in 179(52%) cases followed by RTA in 141(41%) cases. The most common radiological finding was depressed skull fractures in 97(50%) cases. There was 35% mortality in severe head injury patients. Conclusion: This study through some light on the different scenario of head injury in Tribal regions of Developing country and will help to formulate effective strategies for prevention and better care of the patients.

Paediatric traumatic brain injury

Introduction. Traumatic brain injury is a leading cause of death and disability among children, adolescents. Therefore, analysing outcome predictors and initiating preventive policies may contribute to decreased incidence and better prognosis. Aim. Aim to describe the epidemiologic characteristics, mechanism of injury, radiological findings and also to analyse the determinants of outcome that could help to provide better critical care and also to establish effective preventive policies. Material and Methods. We conducted a prospective study including patients ?18 years admitted to our Neuro-intensive care unit at R.N.T. Medical College ,Udaipur, Rajasthan, India from September 2016 to June 2018.Factors including age, gender ,mode of injury, Glasgow coma score(GCS) at admission ,pupillary size-reaction, radiological findings and their relation to outcome was assessed .Patients were divided into mild, moderate and severe head injury according to GCS. Outcome of patients was assessed by Glasgow outcome scale. For statical Analysis used Chisquare test. Statistical Analysis was carried out using Stata 11.0(College station, Texas, USA) Results. The study comprised of 84 paediatric patients. 44.4%of patients were within 1–5-year age group. The most common cause for trauma was falls and traffic accidents. Patients with mild, moderate and severe head injury were 38.1%, 47.6%and 14.3% respectively. Poor outcome predictors included severity of head injury, pupil size and reaction, midline shift on CT. Conclusion. This study emphasizes increased burden of paediatric brain injury with assessment of predicting factors for more effective critical care of patients and emerging need for effective fall and traffic accidents prevention strategies.

Bilateral traumatic basal ganglia haemorrhage, a rare entity

Aims. Traumatic basal ganglia haemorrhage is rare entity but post traumatic bilateral basal ganglia hematoma is even extremely rare and was earlier presented as case reports. Its incidence is about 3% after a closed head injury however, the incidence is higher in post mortem studies. Material & Methods. Out of 1485 head injury patients admitted to our institute from January 2012 to January 2019, there were 9 cases of traumatic bilateral basal ganglia haemorrhage. The incidence of traumatic bilateral basal ganglia Haemorrhage in our series is 0.61% which is very less compared to previous literature. Results. There were 6 males and 3 females; age ranging from 19 to 50 years (average 32 years). Patients with hypertension, history of drugs abuse, history of coagulopathy, with doubtful history of trauma or unknown mode of injury were excluded from the study. The mode of injury in all the patients was road traffic accidents. Average follow up was 9.54 months. Outcome was assessed by Glasgow outcome Score. In 8 out of 9 patients, outcome was good. One patient died. All the nine cases were managed conservatively. Conclusion. We report nine cases from a single institute which to the best of our knowledge is the largest series in world literature. Prognosis is variable and dependent on many factors. The prognosis of TBGH is favourable if not associated with other disorders like hypertension, diabetes mellitus, and coagulation disorders or diffuse axonal injury.

Traumatic posterior fossa extradural hematoma

Background. Extradural hematoma of posterior fossa (PFEDH) is less common and there are not many articles about PFEDH. These patients can deteriorate very rapidly due to compression over brainstem. Thus, early identification and immediate intervention can save the lives of these patients.Objective. This study aims to conduct a comprehensive analysis of patients with PFEDH and evaluate the postoperative outcome which may be of help to make further preventive strategies.Methods and Materials. The study included 16 patients admitted with traumatic PFEDH from July 2016 to July 2018 at R.N.T. Medical College & M.B. Groups of Hospital Udaipur, southwestern Rajasthan, India. We have retrospectively reviewed the data. Analysed factors were gender, age, Glasgow Coma Scale (GCS), Noncontrast CT scan findings, associated brain injury, type of intervention, Glasgow Outcome Scale (GOS). GOS was assessed at discharge, at 3 months and 6 months follow-up.Results. Out of a total of 16 patients, 11 were male and 5 were female with age ranging from 05-46 years. 12 patients had GCS 13 -15 at admission and only one of them had GCS < 8. 15 patients underwent surgical intervention. At 6 months follow-up, 12 patients had good recovery GOS is 5.Conclusion. Early detection and immediate evacuation of PFEDHs should be done if causing fourth ventricle, basal cistern or brain stem compression. It may be rapidly fatal due to the expansion of hematoma leading to brainstem compression, tonsillar herniation, and/or obstructive hydrocephalus. Early detection and immediate evacuation lead to a better outcome in these patients.

Compound Elevated Skull Fracture Presented as a New Variety of Fracture with Inimitable Entity: Single Institution Experience of 10 Cases

Background

Compound elevated Skull fracture (CESF) is a rare variety of fracture with rare presentation in comparison to other type of skull fracture. The mechanical force being applied is tangential causing high impact over skull as comparison to structure underlying the cranium.

Objective

Aims of this study are bring attentiveness and management to deal this rare type of fracture and its outcomes.

Materials and Methods

In this study, we demonstrated 10 cases of CESF in adult patients from January 2014 to January 2018 in the Department of Neurosurgery at RNT Medical College and M. B. Hospital, Udaipur, Rajasthan, India. Recorded documents were prospectively studied for age of distribution, sex, mode of injury, mechanism of injury, clinical profile, radiological investigations, neurosurgical management, and outcome asses by Glasgow outcome scale.

Results

Totally 10 patients had CESF. Six are males and four are females. Male to female ratio was 3:2. Their age range was 20-45 years. The most common mode of injury was Road traffic accident in 60%. Wound exploration, cleaning, debridement, and reduction of fracture segment was done in eight cases, frontal bone craniotomy with evacuation of pneumocephalus done one case, frontal bone craniotomy, and extradural hematoma evacuation was done in one case. The postoperative course was uneventful, and outcome was good (GOS 5) in 8 (80%) cases.

Conclusion

In compound elevated fracture, early recognition and immediate surgical intervention should be done to avoid related morbidity and mortality. Any delay in surgery may lead to a high possibility of wound infection and poor outcome.

Bull horn head injury with retained horn in brain: A rare case report

Pediatric head injuries are a commonly seen emergency in trauma centers worldwide. There are various modes of injury such as fall from height, road traffic accidents, objects hitting the head, assault, and battered baby. We report here a child who presented to us with a history of sustaining head injury by a stray bull on the road and a retained broken bull horn inside the brain and its subsequent management.

Posttraumatic hydrocephalus: Lessons learned from management and evaluation at a tertiary institute with review of literature

Background: Post traumatic hydrocephalus (PTH) is a commonest treatable complication of severe traumatic brain injury that’s leads to failure of improvement and worsening of the outcome. Incidence of posttraumatic hydrocephalus is 0.7%-29% reported in different literature. We have observed the development of PTH frequently seen in patients with severe head injury and after decompressive craniectomy (DC). Pathophysiology includes inflammatory changes and adhesion of arachnoid granulation, cerebral ischemia and alteration in cerebrospinal fluid (CSF) dynamics. We studied 35 cases of PTH diagnosed and treated at our institute from May 2008 to May 2017.

Material and methods: This is hospital based retrospective and prospective study conducted in tertiary center on the basis of neuro-radiological examination of the patient. Clinical biodata and radiological profile of the patients was studied at initial presentation with trauma, and when the patient worsened with symptoms of raised intracranial pressure (ICP) in state of established PTH. These cases were treated by medium pressure ventriculoperitoneal shunt (V.P shunt) and outcome was evaluated.

Results: Incidence of PTH in our study is (2.3%). Out of 35 cases 24 (68.57%) were male and 11(31.4%) were female. Road traffic accident (RTA) was the most common mode of injury (82.85%), acute subdural hematoma (SDH) was the most common finding on C.T scan in 15 cases (42.8 %). Decompressive craniectomy was performed in 77% at time of initial trauma. PTH had favourable outcome with V.P. shunting in 91.42%.

Conclusion: Patients with traumatic brain injury present with many complications but PTH is most frequent sequeale that can present in form of various neurological symptoms after trauma and decompressive craniectomy. C.T. scan brain is the investigation of choice for diagnosis of PTH. Outcome was favourable after V.P. shunt in PTH.

Outcome of surgically treated head injury in unattended patients at Neurosurgery Department in Tertiary Care Centre - an institutional study

This is a prospective study, carried out at our department. Many patients with history of trauma with head injury, whose identity cannot be ascertained, are admitted in our hospital. The management of these unattended patients from pre-hospital till discharge, rehabilitation or death is full of difficulties especially when surgical intervention has to be done. We conducted a prospective study by enrolling 11 consecutive unattended patients in whom neurosurgical procedures performed at our hospital. Out of 11 patients, 9 (82%) were male, most were in the age group of 21-30 years. The mean age was 30 years. Mean duration of hospital stay was 11.27 days. The cause of head injury was road traffic accident in all patients. Majority of the patients 10 (90%) had Glasgow coma scale less than 8 on admission. Two patients 2 (18%) died in hospital, 7 (63%) patients had good recovery. During the course of treatment identity of all 11 patients was established and 8 (72%) patients who survived were discharged to home. All discharged patients were followed at interval of 1 month and 3 months. Four (50%) & 5 (62%) patients showed good recovery (GOS) at 1 month & 3 month respectively

Kinked and retained nasogastric tube in polytrauma patient; a case report

Enteral feeding is an important and preferred technique of feeding in head injury patient to provide nutrition. As inadequate nutrition causes decrease in physical ability, neurological impairment and takes a long time for improvement or delayed deterioratation. With our best knowledge kinked and retained nasogastric tube in stomach is a very rare complication of feeding in head injuries patients. Predisposing factors that can cause kinking is excess tube length, tube in situ for long time and small bore tube. We are reporting one such case of kinked and retained nasogastric tube in the stomach of a polytrauma patient which was retrieved by upper GI endoscope.

Congenital extra calvarial plexiform neurofibroma in occipito-cervical region with Occipital bone defect with neurofibromatosis type 1 and segmental neurofibromatosis: Case report and review of literature

Plexiform neurofibroma (PNF) of the scalp is an extremely rare lesion reported in association with neurofibromatosis (NF). Occipital location of PNF is even more infrequent; we reported one pediatric case of PNF in occipito-cervical region with multiple small occipital bone defects and associated with NF-1.

Large subgaleal hematoma producing turban head in 10 year boy with cerebral palsy: rare case report with review of literature

Subgaleal hematomas (SGHs) are not uncommon. Because the subgaleal space has no anatomical boundaries, SGHs usually involve a large space and are typically limited to the parietal region. Cases of SGHs involving whole of head are relatively rare. In this study we report a rare case of massive enlargement of head after SGH causing severe pain and giving an appearance of turban. A 10 year old, male patient with cerebral palsy presented with progressive enlargement of head attaining a size of turban due to habitual head banging and self-punching overhead. SGH drainage and hematoma aspiration were performed and the patient’s head size was restored.

Traumatic cerebellar hematoma in paediatric patient – a case report and review of literature

Paediatric trauma is common emergency in emergency departments of hospitals worldwide. One of the uniqueness is the trauma sustained mostly in household areas and even the mode of injury is often subtle. Paediatric head injury is the one of the common reasons for children visiting the emergency department. Expert management and gentle care is an essential requirement in paediatric head injury cases. The management of the paediatric traumatic brain injury certainly depends upon the clinical conditions of patient and computed tomography {CT} findings. Most of the traumatic brain injuries can be managed conservatively but at times the surgical management has to be undertaken. A 6 month old child admitted with the history head injury. NCCT head revealed cerebellar hematoma with overlying subdural haemorrhage. Initially the child was managed conservatively but as the sensorium deteriorated the surgical evacuation was performed. The paediatric post fossa traumatic haemorrhage is a relatively uncommon and the management also needs to be individualized as per the patient’s condition.

Posttraumatic delayed tension pneumocephalus: Rare case with review of literature

Pneumocephalus is commonly seen after head and facial trauma, ear infections, and tumors of the skull base or neurosurgical interventions. In tension pneumocephalus, the continuous accumulation of intracranial air is thought to be caused by a "ball valve" mechanism. In turn, this may lead to a mass effect on the brain, with subsequent neurological deterioration and signs of herniation. Tension pneumocephalus is considered a life-threatening, neurosurgical emergency burr-hole evacuation was performed and he experienced a full recovery. However, more invasive surgery was needed to resolve the condition. Delayed tension pneumocephalus is extremely rare and considered a neurosurgical emergency. Pneumocephalus is a complication of head injury in 3.9-9.7% of the cases. The accumulation of intracranial air can be acute (<72 h) or delayed (≥72 h). When intracranial air causes intracranial hypertension and has a mass effect with neurological deterioration, it is called tension pneumocephalus. We represent a clinical case of a 30-year-old male patient with involved in a road traffic accident, complicated by tension pneumocephalus and cerebrospinal fluid rhinorrhea on 1 month after trauma and underwent urgent surgical intervention. Burr-hole placement in the right frontal region, evacuation of tension pneumocephalus. Tension pneumocephalus is a life-threatening neurosurgical emergency case, which needs to undergo immediate surgical intervention.

Epidermoid cyst in Anterior, Middle & Extension of Posterior cranial fossa: rare Imaging with review of literature

Epidermoid cysts are benign slow growing more often extra-axial tumors that insinuate between brain structures, we present the clinical, imaging, and pathological findings in 35 years old female patients with atypical epidermoid cysts which was situated anterior, middle & posterior cranial fossa. NCCT head revealed hypodense lesion over right temporal and perisylvian region with extension in prepontine cistern with mass effect & midline shift and MRI findings revealed a non-enhancing heterogeneous signal intensity cystic lesion in right frontal & temporal region extending into prepontine cistern with restricted diffusion. Patient was detoriated in night of same day of admission, emergency Fronto-temporal craniotomy with anterior peterousectomy and subtotal resection was done. The histological examination confirms the epidermoid cyst. The timing of ectodermal tissue sequestration during fetal development may account for the occurrence of atypical epidermoid cysts.

Superior Mesenteric Artery Syndrome: Diagnosis and Management

Superior mesenteric artery syndrome is a life-threatening rare acquired upper gastrointestinal disorder due to mechanical compression of third part of duodenum by the acute angulation of Superior mesenteric artery, leading to obstruction. Acute loss of intervening mesenteric fat as a result of a variety of debilitating conditions is believed to be the etiologic factor causing the reduced aortomesenteric angle. Abdominal CT angiography showed the dilatation of second part of duodenum and vascular compression of the proximal third part of the duodenum between the aorta and superior mesenteric artery. We report a case of 15 year old young boy who presented with recurrent postprandial pain in the epigastric region, accompanied by epigastric fullness, nausea, postprandial bilious vomiting and weight loss. When conservative measures were ineffective, laparoscopic retrocolic duodenojejunostomy, side to side anastomosis, was performed in the patient to relieve the obstruction. This case report is unusual as it is concerned with the description of a rare disease entity and its radiological appearances for early preoperative diagnosis, better understanding and management of the disease are discussed in the pertinent light of literature.

Outcome of ventriculoperitoneal shunt surgery, without prior placement of external ventricular drain in Grades III and IV patients of tubercular meningitis with hydrocephalus: A single institution's experience in the pediatric population and review of literature

OBJECTIVE

Hydrocephalus is a most common complication of tubercular meningitis (TBM). Relieving hydrocephalus by ventriculoperitoneal shunt (VPS) placement has been considered beneficial in patient in Palur Grades II or III. The role of VPS placement in those of Grades III and IV is controversial, and general tendency is to avoid its use. Some authors have suggested that patient in Grades III and IV should receive a shunt only if their condition improves with a trial placement of external ventricular drain (EVD). However, recent studies suggest that VPS may be undertaken without the trial of an EVD. Our study prospectively evaluates the role of direct VPS placement in patient in Grades III and IV TBM with hydrocephalus (TBMH).

MATERIALS AND METHODS

This study was carried out on 50 consecutive pediatric patients of TBMH in Palur Grades III and IV from July 2013 to December 2014 in R.N.T. Medical College and M.B. Hospital, Udaipur, Rajasthan. All patients underwent direct VPS placement, without prior placement of EVD. The outcome was assessed at the end of 3 months using Glasgow Outcome Score.

RESULTS

The mean age of patients was 3.25 years (range, 3 months-14 years). Forty (80%) patients were in Grade III, and 10 (20%) were in Grade IV. Good outcome and mortality in Grade IV patients were 30% (3/10) and 10% (1/10), respectively; whereas in Grade III patients, it was 77.5% (31/40) and 0% (0/40), respectively. Twenty-five patients presented with focal neurological deficit at admission, which persisted in only 14 patients at 3 months follow-up. VPS-related complications were observed in 5 (10%) patients.

CONCLUSIONS

This study demonstrates that direct VPS surgery could improve the outcome of Grades III and IV TBMH. Despite poor grade at admission, 80% patients in Grade III and 20% patients in Grade IV had a good outcome at 3 months follow-up. Direct VPS placement is a safe and effective option even in a patient in Grades III and IV grade TBMH with a low complication rate.

Large tentorium meningioma causing chiari malformation type-1 with syringomalia with complete resolution of syrinx and chiari after surgical excision: rare case report with review of literature

A 35-year-old female was admitted with a 3-year history of headache, gait disturbance and vertigo on & off and one year history of nasal regurgitation. Magnetic resonance imaging demonstrated a large tentorium meningioma left sided and syringomyelia in the upper cervical cord associated with caudal displacement of the cerebellar tonsil (chiari type -1 malformation). Herniation of the cerebellar tonsil and distortion of the brain stem had probably caused disturbance of cerebrospinal fluid flow which combined with obstruction of the spinal canal, caused the syrinx. Complete excision of the tumor resulted in symptomatic improvement of these symptoms with complete resolution of syrinx & chiari.

A novel SOD mimic with a redox-modulating mn (II) complex, ML1 attenuates high glucose-induced abnormalities in intracellular Ca2+ transients and prevents cardiac cell death through restoration of mitochondrial function

A key contributor to the pathophysiology of diabetic cardiomyopathy, mitochondrial superoxide can be adequately countered by Mn-superoxide dismutase, which constitutes the first line of defense against mitochondrial oxidative stress. Our group has recently synthesized low molecular weight SOD mimics, demonstrating superior protection against oxidative damages to kidney cells. In the current study, we sought to evaluate the protective effect of the SOD mimic ML1 against high glucose induced cardiomyopathy in diabetes. Mechanistic studies using rat cardiac myoblast H9c2 showed that ML1 markedly inhibited High Glucose (HG) induced cytotoxicity. This was associated with increased Mn-SOD expression along with decreased mitochondrial [Formula: see text], ONOO- and Ca²⁺ accumulation, unveiling its anti-oxidant potentials. ML1 also attenuated HG-induced loss of mitochondrial membrane potential (ΔΨ_m) and release of cytochrome c, suggesting that ML1 effectuates its cytoprotective action via the preservation of mitochondrial function. In an ex-vivo model normal adult rat ventricular myocytes (ARVMs) were isolated and cultured in either normal glucose (5.5 mmol/l glucose) or HG (25.5 mmol/l glucose) conditions and the efficiency of ML-1 was analyzed by studying contractile function and calcium indices. Mechanical properties were assessed using a high-speed video-edge detection system, and intracellular Ca²⁺ transients were recorded in fura-2-loaded myocytes. Pretreatment of myocytes with ML1 (10 nM) ameliorated HG induced abnormalities in relaxation including depressed peak shortening, prolonged time to 90% relenghthening, and slower Ca²⁺ transient decay. Thus, ML1 exhibits significant cardio protection against oxidative damage, perhaps through its potent antioxidant action via activation of Mn-SOD.

Traumatic bilateral basal ganglia bleed: A report of rare two cases and review of the literature

Traumatic basal ganglia hemorrhage (TBGH) is relatively uncommon. Bilateral basal ganglia hematoma after trauma is extremely rare and is limited to case reports. We report two cases of traumatic bilateral basal ganglia hemorrhage and review the literature in brief. Both cases were managed conservatively. The general incidence of TBGH is reported between 2.4% and 3% of closed head injury. However, the incidence is higher in postmortem studies (9.8%). Bilateral traumatic basal ganglia hematoma is extremely rare. Descriptions are limited to case reports.

Gunshot wound causing complete spinal cord injury without mechanical violation of spinal axis: Case report with review of literature

Penetrating spine injury (PSI) forms the third most common cause of spine injury, only next to road traffic accidents and fall. Gunshot wound (GSW) forms the major bulk of PSI. Due to easy availability of firearms and antisocial behavior, GSW which were predominant in military population is now increasingly seen in civilized society. Here, we present a detail case review of unique case of civilian GSW indirectly causing complete spinal cord injury due to shock wave generated by the bullet, along with its systematic management.

A review on biological sources, chemistry and pharmacological activities of pinostrobin

Pinostrobin, a dietary bioflavonoid discovered more than 6 decades ago in the heart-wood of pine (Pinus strobus), has depicted many pharmacological activities including anti-viral, anti-oxidant, anti-leukaemic, anti-inflammatory and anti-aromatase activities. It is an inhibitor of sodium channel and Ca(2+) signalling pathways and also inhibits intestinal smooth muscle contractions. In spite of the fact that pinostrobin has an application as functional foods, till-to-date no comprehensive review on pinostrobin has been carried out. Hence, the present review deals with the biological sources, chemistry and pharmacological activities of pinostrobin.

Penetrating spinal injuries and their management

Penetrating spinal trauma due to missile/gunshot injuries has been well reported in the literature and has remained the domain of military warfare more often. Civic society's recent upsurge in gunshot injuries has created a dilemma for the treating neurosurgeon in many ways as their management has always involved certain debatable and controversial issues. Both conservative and surgical management of penetrating spinal injuries (PSI) have been practiced widely. The chief neurosurgical concern in these types of firearm injuries is the degree of damage sustained during the bullet traversing through the neural tissue and the after-effects of the same in long term. We had an interesting case of a penetrating bullet injury to cervical spine at C2 vertebral level. He was operated and the bullets were removed from posterior midline approach. Usually, the management of such cases differs from region to region depending on the preference of the surgeon but still certain common principles are followed world over. Thus, we realized the need to review the literature regarding spinal injuries with special emphasis on PSI and to study the recent guidelines for their treatment in light of our case.

Levels of malondialdehyde and antioxidants in the blood of patients with vitiligo of age group 11-20 years

The aetiopathogenesis of vitiligo has not been fully understood. To investigate the role of oxidative stress in pathogenesis of vitiligo, we examined the blood level of antioxidants and malondialdehyde in 40 patients with generalized vitiligo and 40 healthy volunteers belonging to same age group. Our results revealed that the level of malondialdehyde was significantly raised while those of vitamin E, uric acid and ceruloplasmin were significantly lowered (P < 0.05) in patients with generalized vitiligo as compared to controls. This demonstrates the presence of an imbalance in the oxidant-antioxidant system in the blood of vitiligo patients and thus provides support for a free radical mediated damage as a pathogenic event in vitiligo.

Effect of centrally administered glucagon on liver glycogen & enzymes in anaesthetised dogs

Glucagon (0.01 microgram) administered through the intracerebroventricular route in anaesthetised mongrel dogs, caused a significant rise in blood glucose and a fall in liver glycogen (P less than 0.01). Concurrently, it increased the liver phosphorylase, glutamic oxaloacetic transaminase, glutamic pyruvic transminase and lipase activities by 30 min. Identical changes were observed in vagotomised animals. In pancreatectomised animals as well as in spinal cord transectomised animals, glucagon did not cause these changes. The study indicated that the hyperglycaemia produced by the centrally administered glucagon, is possibly a result of liver glycogenolysis and gluconeogenesis induced by endogenous glucagon secreted from the pancreas, the stimulus for which is the hypothalamo-pancreatic fibres responding to glucagon sensitive neurones in the hypothalamus.

Effect of centrally administered glucagon on blood lipids in anesthetised dogs

Previously we have proposed the existence of the central glucagon sensitive receptors in dogs. The present study was undertaken to explore the role of centrally administered glucagon on lipids in view of the proposed theory that the hypothalamic lipomobilizing centres are sensitive to glucose or substances that affect glucose metabolism. Glucagon (0.01 microgram) administered through the intracerebroventricular (ICV) route in anesthetised mongrel dogs, caused hypolipidemia (P greater than 0.001), hypocholesterolemia (P greater than 0.001), decreased blood free fatty acid (P greater than 0.001) and triglycerides (P greater than 0.001) levels; but increased blood high density lipoprotein (P greater than 0.01) level at 30 min. These effects on the central administration of glucagon, were not observed in pancreatectomised animals and spinal cord transectomised animals. Therefore, we conclude that the lipolysis on the central administration of glucagon, is caused by the endogenous glucagon secreted from the pancreas through the sympathetic fibers.