RE-OPEN: Randomised trial of biosimilar TNK versus TPA during endovascular therapy for acute ischaemic stroke due to large vessel occlusions

Rationale

Rapid and timely treatment with intravenous thrombolysis and endovascular treatment (EVT) in patients with acute ischaemic stroke (AIS) and large vessel occlusion (LVO) significantly improves patient outcomes. Bridging therapy is the current standard of care in these patients. However, an incompletely answered question is whether one thrombolytic agent is better than another during bridging therapy.

Aim

The current study aims to understand if one thrombolytic agent is superior to the other during bridging therapy in the treatment of AIS and LVO.

Sample size estimates

Using 80% power and an alpha error of 5 %, presuming a 10% drop out rate, a total of 372 patients will be recruited for the study.

Methods and design

This study is a prospective, randomised, multicentre, open-label trial with blinded outcome analysis design.

Study outcomes

The primary outcomes include proportion of patients who will be independent at 3 months (modified Rankin score (mRS) ≤2 as good outcome) and proportion of patients who achieve recanalisation modified thrombolysis in cerebral infarction grade 2b/3 at first angiography run at the end of EVT. Secondary outcomes include proportion of patients with early neurological improvement, rate of symptomatic intracerebral haemorrhage (ICH), rate of any ICH, rate of any systemic major or minor bleeding and duration of hospital stay. Safety outcomes include any intracranial bleeding or symptomatic ICH.

Discussion

This trial is envisioned to confirm the theoretical advantages and increase the strength and quality of evidence for use of tenecteplase (TNK) in practice. Also, it will help to generate data on the efficacy and safety of biosimilar TNK.

Trial registration number

CTRI/2022/01/039473.

The role of susceptibility-weighted imaging & contrast-enhanced MRI in the diagnosis of primary CNS vasculitis: a large case series

Primary CNS Vasculitis (PCNSV) is a rare, diverse, and polymorphic CNS blood vessel inflammatory condition. Due to its rarity, clinical variability, heterogeneous imaging results, and lack of definitive laboratory markers, PCNSV diagnosis is challenging. This retrospective cohort analysis identified patients with histological diagnosis of PCNSV. Demographic data, clinical presentation, neuroimaging studies, and histopathologic findings were recorded. We enrolled 56 patients with a positive biopsy of CNS vasculitis. Most patients had cerebral hemisphere or brainstem symptoms. Most brain MRI lesions were bilateral, diffuse discrete to confluent white matter lesions. Frontal lobe lesions predominated, followed by inferior cerebellar lesions. Susceptibility-weighted imaging (SWI) hemorrhages in 96.4% (54/56) of patients, either solitary microhemorrhages or a combination of micro and macrohemorrhages. Contrast-enhanced T1-WIs revealed parenchymal enhancement in 96.3% (52/54 patients). The most prevalent pattern of enhancement observed was dot-linear (87%), followed by nodular (61.1%), perivascular (25.9%), and patchy (16.7%). Venulitis was found in 19 of 20 individuals in cerebral DSA. Hemorrhages in SWI and dot-linear enhancement pattern should be incorporated as MINOR diagnostic criteria to diagnose PCNSV accurately within an appropriate clinical context. Microhemorrhages in SWI and venulitis in DSA, should be regarded as a potential marker for PCNSV.

Isolated ipsilateral abducens nerve palsy and contralateral homonymous hemianopsia associated with unruptured posterior cerebral artery aneurysm: A rare neurological finding

Cranial nerve palsies can be presenting signs of intracranial aneurysms. There is a classic pairing between an aneurysmal vessel and adjacent nerves leading to cranial neuropathy. Isolated abducens nerve palsy can be a localizing sign of an unruptured vertebrobasilar circulation aneurysm. Aneurysms involving Anterior Inferior Cerebellar Artery (AICA) and Posterior Inferior Cerebellar Artery (PICA) have been reported to be associated with abducens nerve palsy. The symptoms in unruptured aneurysms are due to the mass effect on adjacent neurovascular structures. Most of the abducens nerve palsy resolves following microsurgical clipping. Here, we present a rare case of an unruptured Posterior Cerebral Artery (PCA) aneurysm presenting with abducens nerve palsy and diplopia associated with contralateral hemianopsia which markedly improved following endovascular coil embolization.

Measurement of Neutrophil Gelatinase-Associated Lipocalin (Ngal) Following Neuroradiological Procedure/s in Patients with Aneurysmal Subarachnoid Hemorrhage: A Preliminary Study

Background

Radiocontrast administration during interventional neuroradiology (INR) procedures for aneurysmal subarachnoid haemorrhage (aSAH) can add to renal insult. Serum creatinine (sCr) is a conventional marker of acute kidney injury (AKI). Serum neutrophil gelatinase-associated lipocalin (sNGAL) is a novel marker which is increasingly used to predict renal injury in susceptible patients.

Objectives

The primary aim of this study was to evaluate correlation between serum neutrophil gelatinase-associated lipocalin (NGAL) and sCr in aSAH patients undergoing therapeutic or diagnostic INR procedures. The secondary aim was to find the incidence of contrast-induced AKI and hemodynamic complications during the study period.

Material and Methods

All consenting aSAH patients (18-60 years, Modified Hunt and Hess grade 1-4) posted for INR procedures during the study time were included. Patients with history of chronic renal disease, recent contrast exposure, or renal insufficiency were excluded. Blood samples for sCr and sNGAL were obtained preprocedure and then at 1, 6, 24, and 48 h after contrast administration. Hourly urine output was noted. AKI was defined by KDIGO guidelines.

Statistical Analysis Used

Repeated measurement analysis of variance, Posthoc Bonferroni test and Pearson correlation coefficient test.

Results

Fifty patients, mean age 47.34 ± 9.31 years, were enrolled for the study. Majority (48; 96%) were Hunt and Hess (H and H) grade I-III. The mean volume of contrast administered was 123.2 ± 53.08 mL. The mean sNGAL and sCr values at pre-op, 1, 6, 24, and 48 h were 124.99 ± 64.58, 148.40 ± 77.90, 147.33 ± 76.00, 125.49 ± 64.44, and 116.38 ± 61.79 ng/mL and 0.629 ± 0.23, 0.624 ± 0.22, 0.612 ± 0.21, 0.632 ± 0.19, and 0.577 ± 0.22 mg/dL, respectively. There was a correlation in sCr and sNGAL value (P < 0.001) at all study time points. However, no specific pattern was seen. No patient developed any AKI or hemodynamic complications in first 48 h.

Conclusions

There is a correlation between serum NGAL and sCr at individual time points. NGAL may represent a sensitive early biomarker of renal impairment after INR Procedures. There was no incidence of AKI after contrast administration in aSAH patients without predisposing renal risk factors.

World Federation for Interventional Stroke Treatment (WIST) Multispecialty Training Guidelines for Endovascular Stroke Intervention

INTRODUCTION

Today, endovascular treatment (EVT) is the therapy of choice for strokes due to acute large vessel occlusion, irrespective of prior thrombolysis. This necessitates fast, coordinated multi-specialty collaboration. Currently, in most countries, the number of physicians and centres with expertise in EVT is limited. Thus, only a small proportion of eligible patients receive this potentially life-saving therapy, often after significant delays. Hence, there is an unmet need to train a sufficient number of physicians and centres in acute stroke intervention in order to allow widespread and timely access to EVT.

AIM

To provide multi-specialty training guidelines for competency, accreditation and certification of centres and physicians in EVT for acute large vessel occlusion strokes.

MATERIAL AND METHODS

The World Federation for Interventional Stroke Treatment (WIST) consists of experts in the field of endovascular stroke treatment. This interdisciplinary working group developed competency - rather than time-based - guidelines for operator training, taking into consideration trainees' previous skillsets and experience. Existing training concepts from mostly single specialty organizations were analysed and incorporated.

RESULTS

The WIST establishes an individualized approach to acquiring clinical knowledge and procedural skills to meet the competency requirements for certification of interventionalists of various disciplines and stroke centres in EVT. WIST guidelines encourage acquisition of skills using innovative training methods such as structured supervised high-fidelity simulation and procedural performance on human perfused cadaveric models.

CONCLUSIONS

WIST multispecialty guidelines outline competency and quality standards for physicians and centres to perform safe and effective EVT. The role of quality control and quality assurance is highlighted.

SUMMARY

The World Federation for Interventional Stroke Treatment (WIST) establishes an individualized approach to acquiring clinical knowledge and procedural skills to meet the competency requirements for certification of interventionalists of various disciplines and stroke centres in endovascular treatment (EVT). WIST guidelines encourage acquisition of skills using innovative training methods such as structured supervised high-fidelity simulation and procedural performance on human perfused cadaveric models. WIST multispecialty guidelines outline competency and quality standards for physicians and centers to perform safe and effective EVT. The role of quality control and quality assurance is highlighted.

SIMULTANEOUS PUBLICATION

The WIST 2023 Guidelines are published simultaneously in Europe (Adv Interv Cardiol 2023).

Effects of sedimentary heavy metals on meiobenthic community in tropical estuaries along eastern Arabian Sea

The central west coast of India comprises the 720 km long coastline of Maharashtra state and houses widespread industrial zones along the eastern Arabian Sea. Sediments from seven industrial-dominated estuaries along the central west coast were studied for metal enrichment and benthic assemblages to determine sediment quality status and ecological effects in these areas. The suit of geochemical indices highlighted the contamination of sediment in the estuaries concerning heavy metals. Positive correlations of Hg with Co, Zn, Ni, Cr, and Pb indicated the source similarity and effect of anthropogenic activity. non-Metric Multidimensional Scaling (n-MDS) based on meiofaunal abundance showed a cleared separation of clusters through the gradient of heavy metal concentrations. The Canonical Correspondence Analysis (CCA) results with the Monte Carlo test signified those heavy metals influenced the meiobenthic community. Heavy metals (Cr, Ni, Zn, Cd, Pb, and Hg) were the main drivers shaping the meiofaunal community with a significant (p < 0.05) reduction in taxa richness, diversity, and evenness. Dominant meiofaunal assemblages evidence the tolerance of foraminiferans and nematodes. However, these taxa were affected by decreased abundance at impacted sites compared to other fauna. In conclusion, results demonstrated that impairment occurred in the meiofaunal community in most estuaries (except AB and KK).

Clinical and radiological spectrum of anti-myelin oligodendrocyte glycoprotein (MOG) antibody encephalitis: single-center observational study

OBJECTIVE

The objective was to describe the clinical presentations, radiologic features, and outcomes of patients with autoimmune encephalitis associated with myelin oligodendrocyte glycoprotein antibody (MOG).

BACKGROUND

During the past decade, the spectrum of the myelin oligodendrocyte glycoprotein antibody-associated diseases (MOGAD) has expanded. Recently, patients with MOG antibody encephalitis (MOG-E) who do not fulfill the criteria for ADEM have been reported. In this study, we aimed to describe the spectrum of MOG-E.

METHODS

Sixty-four patients with MOGAD were screened for encephalitis-like presentation. We collected the clinical, radiological, laboratory, and outcome data of the patients who presented with encephalitis and compared it with the non-encephalitis group.

RESULTS

We identified sixteen patients (nine males and seven females) with MOG-E. The median age of the encephalitis population was significantly lower than the non-encephalitis group (14.5 years (11.75-18) vs. 28 years (19.75-42), p = 0.0004). Twelve out of sixteen patients (75%) had fever at the time of encephalitis. Headache and seizure were present in 9/16 (56.2%) and 7/16 (43.75%) patients, respectively. FLAIR cortical hyperintensity was present in 10/16 (62.5%) patients. Supratentorial deep gray nuclei were involved in 10/16 (62.5%) patients. Three patients had tumefactive demyelination, and one patient had a leukodystrophy-like lesion. Twelve of 16 (75%) patients had a good clinical outcome. Patient with leukodystrophy pattern and other with generalized CNS atrophy showed a chronic progressive course.

CONCLUSION

MOG-E can have heterogeneous radiological presentations. FLAIR cortical hyperintensity, tumefactive demyelination, and leukodystrophy-like presentations are novel radiological presentations associated with MOGAD. Though majority of MOG-E have a good clinical outcome, few patients can have chronic progressive disease even on immunosuppressive therapy.

Cortico-limbic disruption, material-specificity, and deficits in cognitive-affective theory of mind

The Theory of Mind deficit due to cognitive-affective disintegration is a poorly understood cognitive consequence of cortical and subcortical disruption in right temporal lobe epilepsy. Following Marr's trilevel approach, we used the material-specific processing model to understand the Theory of Mind deficit in drug-resistant epilepsy (N = 30). We examined pre- and post-surgery changes in first-order (somatic-affective, non-verbal component) and second-order Theory of Mind (cognitive-verbal component) in three groups formed using: (i) seizure side (right versus left), (ii) right temporal epilepsy (right temporal lobe epilepsy versus non-right temporal lobe epilepsy), and (iii) right temporal lobe epilepsy with amygdalohippocampectomy (right temporal lobe epilepsy versus left temporal lobe epilepsy amygdalohippocampectomy versus non-amygdalohippocampectomy). We observed a marked deficit in the first-order Theory of Mind in the right temporal lobe amygdalohippocampectomy group; we mapped this deficit to decline in the non-verbal component of Theory of Mind (somatic-affective component). Preliminary results support using a material-specific processing model to understand the Theory of Mind deficits in right temporal lobe epilepsy amygdalohippocampectomy. Malleability of verbal processing in presence of deterioration of non-verbal processing might have clinical relevance for post-surgery recovery in right temporal lobe epilepsy amygdalohippocampectomy. Documenting the material-specific nature of deficits (verbal versus non-verbal) in non-western, linguistically, and socioeconomically diverse country enables us to understand the problem of heterogeneity in post-surgery cognitive consequences in the right amygdalohippocampectomy.

Feasibility of Tailored Unilateral Disconnection vs Callosotomy for Refractory Epilepsy in Patients with Bilateral Parieto-Occipital Gliosis Following Perinatal Insult

BACKGROUND

Patients with perinatal hypoxia (PH) and drug-refractory epilepsy (DRE) often have bilateral parieto-occipital gliosis. Surgical management of such patients is a dilemma.

OBJECTIVE

To identify preoperative determinants for unilateral disconnection vs callosotomy, and analyze the surgical outcome in such patients.

METHODS AND MATERIAL

This was a retrospective analysis of patients with DRE and history of PH, with MRI abnormalities restricted to bilateral posterior quadrants. Preoperative semiology, epilepsy duration and seizure frequency were recorded. Based on the concordance between the results of non-invasive tests, patients underwent either posterior quadrant disconnection (PQD) or corpus callosotomy (CC). Preoperative variables were analyzed and corelated to the postoperative seizure freedom.

RESULTS

Fourteen patients were identified, 6 underwent PQD and 8 underwent CC. At follow up of 39.17 ± 23.75 months, 66.66% of patients (4/6) in the PQD subgroup had an ILAE Class I outcome. While none in the CC group attained seizure freedom, 87.5% (7/8) had more than 50% reduction in seizure frequency (follow up: 42 ± 27.31 months). Patients with a poor outcome had significantly greater seizure frequency (P = 0.05) and history of drop attacks (P = 0.04) in both the groups. Magnetoencephalography (MEG) accurately localized the epileptogenic zone in all of the patients with good outcome (P = 0.015). Concordance with single photon emission tomography (SPECT) was also a predictor of favorable outcome (P = 0.041).

CONCLUSIONS

A history of drop attacks with high seizure frequency is associated with poor postoperative seizure outcome. Unilateral PQD is feasible and leads to superior seizure-free outcomes, even in cases with widespread and bilateral imaging and electrical abnormalities, provided the other preoperative investigations are concordant in localizing the epileptogenic zone.

Concomitant pulmonary disease is common among patients with extrapulmonary TB

BACKGROUND :

Microbiologic screening of extrapulmonary TB (EPTB) patients could inform recommendations for aerosol precautions and close contact prophylaxis. However, this is currently not routinely recommended in India. Therefore, we estimated the proportion of Indian patients with EPTB with microbiologic evidence of pulmonary TB (PTB).

METHODS :

We characterized baseline clinical, radiological and sputum microbiologic data of 885 adult and pediatric TB patients in Chennai and Pune, India, between March 2014 and November 2018.

RESULTS :

Of 277 patients with EPTB, enhanced screening led to the identification of 124 (45%) with concomitant PTB, including 53 (19%) who reported a cough >2 weeks; 158 (63%) had an abnormal CXR and 51 (19%) had a positive sputum for TB. Of 70 participants with a normal CXR and without any cough, 14 (20%) had a positive sputum for TB. Overall, the incremental yield of enhanced screening of patients with EPTB to identify concomitant PTB disease was 14% (95% CI 12–16).

CONCLUSIONS :

A high proportion of patients classified as EPTB in India have concomitant PTB. Our results support the need for improved symptom and CXR screening, and recommends routine sputum TB microbiology screening of all Indian patients with EPTB.

Endoscopic Hemispherotomy for Nonatrophic Rasmussen's Encephalopathy

Background

Hemispheric disconnection represents a challenging and major epilepsy surgical procedure. This procedure in experienced hands offers excellent results in terms of seizure outcomes, especially for hemispheric pathologies such as Rasmussen's encephalitis, hemispheric dysplasias, hemimegalencephaly. The technique of hemispherotomy has witnessed various modifications over the years, beginning from anatomical hemispherectomy to the current era of minimally invasive functional hemispheric disconnections.

Objective

This study aimed to describe the technique of performing endoscopic vertical hemispherotomy using interhemispheric corridor developed by the senior author.

Materials and Methods

A 12-year-old girl with seizure onset at the age of 10 years presented with an aura of fear and nausea followed by tonic deviation of eyes to the right and blinking with speech arrest. There were tonic-clonic movements of the right-sided limbs along with ictal spitting and occasional deviation of the angle of mouth to the right. The patient had loss of awareness for the event along with postictal confusion lasting few minutes.

Results

Video electroencephalography (VEEG) revealed left parietocentral and left temporal localization. Serial magnetic resonance imaging (MRI) brain over 3 years revealed progressive left hemispheric changes suggestive of Rasmussen's encephalitis. The patient underwent left-sided endoscopic hemispherotomy. At 2 years follow-up, the patient is seizure-free (ILAE [International League Against Epilepsy] Class 1).

Conclusion

Endoscopic hemispherotomy using the interhemispheric approach is an elegant, minimally invasive, reproducible, safe, and efficacious technique.

En-bloc Resection of A Giant Solid Hemangioblastoma of The Vermis

INTRODUCTION

Hemangioblastomas (HMB) are extensively vascularized and benign neoplasms that are diagnosed predominantly in adults. The solid type of HMB is technically challenging to operate. The piecemeal resection of the tumor has been shown to have devastating intraoperative complications. Therefore, en-bloc tumor resection was shown to be the safest procedure to reduce the risk of intraoperative bleeding and facilitate the removal of large solid tumors. Unfortunately, most of these tumours are also not amenable for embolization, as they are fed by multiple pial vessels. However, the large arterial feeders may be embolized.

OBJECTIVE

This video abstract presents a case of en-bloc resection of a giant solid type of Vermian HMB.

SURGICAL TECHNIQUE

A 38-year-old male patient presented with headache and vomiting for 1 year, imbalance during walking for 6 months, and hoarseness of voice for 2 months. He underwent a CSF diversion procedure in another hospital and was referred to our center for definitive surgery. Contrast-enhanced MRI showed a large heterogeneously enhancing solid lesion of size 46 × 33 × 40 mm3 with central necrotic area in the posterior fossa with perilesional edema and several large flow voids on T2-MR sequence. Preoperative embolization was performed; however, there was no significant reduction in the vascularity of the lesion. The patient underwent a wide midline suboccipital craniotomy with C1 laminectomy and gross total en-bloc resection of HMB.

RESULTS

The patient had an uneventful recovery in the postoperative period.

CONCLUSIONS

The safest approach in the resection of giant solid HMB involves proper preoperative planning and understanding the vascular pattern of the lesion, wide exposure, circumferential dissection, and the en-bloc delivery of the tumor.

Measuring TB drug levels in the hair in adults and children to monitor drug exposure and outcomes

INTRODUCTION: Testing for anti-TB drugs in small hair samples may serve as a non-invasive tool to measure cumulative drug exposure and/or adherence, as these determine treatment success. We aimed to assess how well hair assays of TB drugs predict TB treatment outcomes.METHODS: A small thatch of hair, ~30 strands, was cut from the occipital region in adults and children from a prospective TB cohort in India. Isoniazid (INH), acetyl-INH and pyrazinamide (PZA) were extracted from the hair samples and quantified using liquid-chromatography-tandem mass spectrometry. The relationship between drug concentrations in hair and time to unfavourable outcomes was assessed using Cox-proportional hazards regression models.RESULTS: A two-fold increase in hair acetyl-INH concentrations in the 264 participants in our cohort with hair assays for TB drugs indicated a lower hazard of unfavourable TB treatment outcomes (aHR 0.67, 95%CI 0.44-1.02) and TB treatment failure (aHR 0.65, 95%CI 0.42-1.01). Higher summed concentrations (a summed measure of INH and acetyl-INH) indicated a lower hazard of treatment failure (aHR 0.69, 95%CI 0.45-1.05)CONCLUSION: Hair levels of INH and its metabolite may predict TB treatment outcomes, indicating the potential utility of this measure to assess and optimise TB treatment outcomes.

Unhealthy alcohol use independently associated with unfavorable TB treatment outcomes among Indian men

BACKGROUND: Approximately 10% of incident TB cases worldwide are attributable to alcohol. However, evidence associating alcohol with unfavorable TB treatment outcomes is weak.METHODS: We prospectively evaluated men (≥18 years) with pulmonary TB in India for up to 24 months to investigate the association between alcohol use and treatment outcomes. Unhealthy alcohol use was defined as a score of ≥4 on the Alcohol Use Disorders Identification Test-Concise (AUDIT-C) scale at entry. Unfavorable TB treatment outcomes included failure, recurrence, and all-cause mortality, analyzed as composite and independent endpoints.RESULTS: Among 751 men, we identified unhealthy alcohol use in 302 (40%). Median age was 39 years (IQR 28-50); 415 (55%) were underweight (defined as a body mass index [BMI] <18.5 kg/m²); and 198 (26%) experienced an unfavorable outcome. Unhealthy alcohol use was an independent risk factor for the composite unfavorable outcome (adjusted incidence rate ratio [aIRR] 1.47, 95% CI 1.05-2.06; P = 0.03) and death (aIRR 1.90, 95% CI 1.08-3.34; P = 0.03), specifically. We found significant interaction between AUDIT-C and BMI; underweight men with unhealthy alcohol use had increased risk of unfavorable outcomes (aIRR 2.22, 95% CI 1.44-3.44; P < 0.001) compared to men with BMI ≥18.5 kg/m² and AUDIT-C <4.CONCLUSION: Unhealthy alcohol use was independently associated with unfavorable TB treatment outcomes, highlighting the need for integrating effective alcohol interventions into TB care.

Post-traumatic Sacral Epidermoid Cyst Masquerading as Chordoma on Imaging: A Case Report

Intradural spinal epidermoid cysts are rare, benign lesions either acquired from trauma, surgery, lumbar puncture or arise as congenital lesions, particularly associated with spinal dysraphism. Epidermoid cyst arising from the spine with expansile destruction of vertebrae has not been reported yet in the literature. We report a case of 36-years male presented with history of fall 8 years back with progressive symptoms of lower back pain, weakness of left lower limb and bladder/bowel incontinence. Computed tomography revealed large lytic expansile, midline sacral vertebral lesion with soft tissue component and multiple calcific foci. Magnetic resonance imaging demonstrated large non-enhancing heterogeneous mass showing restricted diffusion on diffusion weighted images. The patient underwent biopsy confirming the diagnosis of an epidermoid cyst. The possibility of an epidermoid tumor should be kept in the differential diagnosis in patients presenting with posttraumatic sacral mass.

Assessment of the Xpert assay among adult pulmonary tuberculosis suspects with and without diabetes mellitus

SETTING: Pune and Pimpri-Chinchwad Municipal Corporation area, Maharashtra State, India.OBJECTIVE: To assess the sensitivity and specificity of the Xpert® MTB/RIF assay among adults with suspected pulmonary tuberculosis (PTB) and with or without diabetes (DM).DESIGN: As part of a prospective cohort study, we screened 2359 adults presumed to have PTB with no history of TB. All individuals underwent testing for two sputum smears, culture, Xpert, glycated haemoglobin and fasting blood sugar. We calculated sensitivity and specificity of Xpert by comparing it with TB sputum culture result as a gold standard.RESULTS: Among screened individuals, 483 (20%) were diagnosed with DM and 1153 (49%) with pre-DM; 723 (31%) had no DM. Overall sensitivity of Xpert was 96% (95%CI 95–97) and specificity was 91% (95%CI 89–93). Xpert sensitivity was significantly higher among DM group (98%) than in the ‘No DM' (95%; P < 0.01) and pre-DM (96%; P < 0.05) groups. Among sputum smear-negative individuals, Xpert sensitivity was higher in the DM group than in the No DM (92% vs. 82%; P = 0.054) and pre-DM group (92% vs. 82%; P = 0.037).CONCLUSION: High sensitivity and specificity of Xpert underscores the need for its rapid scale up for the early detection of TB in settings with a high dual burden of TB and DM.

Management of Arterial Pseudoaneurysms of the Neck in a Pediatric Population: An Endovascular Case Series and Review of Literature

BACKGROUND

Arterial pseudoaneurysms of the neck are rarely reported in the pediatric population and no dedicated large series are available. Trauma and infection are the most common causes for these aneurysms, with congenital and collagen vascular disorders being the less common causes. These lesions can be life threatening, especially when they present with bleeding or airway compromise.

METHODS

We searched our radiology information system for all cases of pediatric neck aneurysm presented between June 2015 and May 2018. These cases were analyzed for clinicoepidemiologic variables, clinical presentation, imaging findings, management, and follow-up.

RESULTS

Six children were included in the study (male/female ratio, 5:1), with a mean age of 7.8 years (range, 2.5-15 years). Four presented acutely with either bleeding or rapidly enlarging neck swelling, whereas 2 presented with slowly increasing pulsatile swelling. One had a traumatic cause, 2 had infections, and 1 had infective cervical lymphadenitis complicated by iatrogenic injury whereas no definite causative mechanisms could be accounted for in 2 patients. Two of the children were managed by trapping of the aneurysm and 2 only by proximal parent vessel occlusion. The other 2 children were treated with stent graft deployment across the aneurysm neck to reconstruct the parent vessel. All the patients were doing well during the follow-up period (mean, 14.8 months).

CONCLUSIONS

Endovascular means of treatment for pediatric neck aneurysms is relatively simple and safe. Although parent vessel sacrifice is the gold-standard management, vessel-preserving strategies can be tried in select cases with favorable anatomy.

Spinal Cerebrospinal Fluid Drainage for prevention of Vasospasm in Aneurysmal Subarachnoid Hemorrhage: A Prospective, Randomized controlled study

Introduction

Cerebral vasospasm following aneurysmal subarachnoid hemorrhage (SAH) is a major cause of mortality and morbidity. Despite various treatment modalities, the optimal management of vasospasm remains elusive. In this regard; we undertook a prospective, randomized controlled study to evaluate the effectiveness of lumbar cerebrospinal fluid drainage (LCSFD) for prevention of cerebral vasospasm and its sequelae.

Materials and Methods

Patients with aneurysmal SAH who met the inclusion criteria were randomized into two groups - Group I (30 patients) underwent LCSFD whereas Group II (30 patients) did not undergo LCSFD. All patients underwent aneurysmal clipping. Both the groups received standard neurosurgical treatment except for LCSFD. The outcome was measured in terms of (1) clinically evident vasospasm; (2) vasospasm-related cerebral infarction; (3) condition of the patient at the time of discharge; and (4) Glasgow outcome score (GOS) at 1- and 3-month follow-up.

Results

LCSFD conferred a statistically significant benefit reducing the incidence of clinical vasospasm from 63% (in non-LCSFD group) to 30% (in LCSFD group) (P = 0.01) and incidence of vasospasm-related cerebral infarction from 53% (in non-LCSFD group) to 20% (in LCSFD group) (P = 0.007). Incidence of vasospasm was quantitatively lower in LCSFD group across all Hunt and Hess grades; however, it was statistically significant in SAH Grade III (P = 0.008). Mean duration of hospital stay was slightly lower in LCSFD group compared to non-LCSFD group; however, it did not reach statistical significance. A higher incidence of meningitis in LCSFD group was not statistically significant. A higher GOS was observed in LCSFD group at 1- and 3-month follow-up as compared to non-LCSFD group.

Conclusion

Drainage of CSF through a lumbar drain following aneurysmal SAH caused a statistically significant reduction in the incidence of clinical and radiological vasospasm and its sequelae. It also shortens the overall duration of hospital stay and improves the outcome as evidenced by a better GOS score at 1- and 3-month follow-up. The results of this prospective, randomized study establish the efficacy of LCSFD in prevention of vasospasm following aneurysmal SAH.

Comparison of Kaposi Sarcoma Risk in Human Immunodeficiency Virus-Positive Adults Across 5 Continents: A Multiregional Multicohort Study

BACKGROUND

We compared Kaposi sarcoma (KS) risk in adults who started antiretroviral therapy (ART) across the Asia-Pacific, South Africa, Europe, Latin, and North America.

METHODS

We included cohort data of human immunodeficiency virus (HIV)-positive adults who started ART after 1995 within the framework of 2 large collaborations of observational HIV cohorts. We present incidence rates and adjusted hazard ratios (aHRs).

RESULTS

We included 208140 patients from 57 countries. Over a period of 1066572 person-years, 2046 KS cases were diagnosed. KS incidence rates per 100000 person-years were 52 in the Asia-Pacific and ranged between 180 and 280 in the other regions. KS risk was 5 times higher in South African women (aHR, 4.56; 95% confidence intervals [CI], 2.73-7.62) than in their European counterparts, and 2 times higher in South African men (2.21; 1.34-3.63). In Europe, Latin, and North America KS risk was 6 times higher in men who have sex with men (aHR, 5.95; 95% CI, 5.09-6.96) than in women. Comparing patients with current CD4 cell counts ≥700 cells/µL with those whose counts were <50 cells/µL, the KS risk was halved in South Africa (aHR, 0.53; 95% CI, .17-1.63) but reduced by ≥95% in other regions.

CONCLUSIONS

Despite important ART-related declines in KS incidence, men and women in South Africa and men who have sex with men remain at increased KS risk, likely due to high human herpesvirus 8 coinfection rates. Early ART initiation and maintenance of high CD4 cell counts are essential to further reducing KS incidence worldwide, but additional measures might be needed, especially in Southern Africa.

Development of a highly immunogenic Newcastle disease virus chicken vaccine strain of duck origin

Newcastle disease virus (NDV) strain NDRL0901 was developed as a live vaccine candidate for control of Newcastle disease. NDV isolate KR/duck/13/07 (DK1307) of duck origin was used as the selected vaccine strain. DK1307 was passaged 6 times in chickens. Then a single clone from the chicken-adapted virus (DK1307C) was finally selected, and the vaccine strain was named NDRL0901. DK1307C and the clone NDRL0901 viruses showed enhanced immunogenicity compared to the DK1307 virus. Principal component analysis based on fusion and hemagglutinin-neuraminidase genes revealed the codon usage pattern in the dataset is distinct separating duck viral sequences and avian sequences, and passage of the duck origin virus into the chicken host causes deviation in the codon usage pattern. The NDRL0901 virus was avirulent and did not acquire viral virulence even after 7 back passages in chickens. When day-old chicks were vaccinated with the NDRL0901 virus via spray, eye drops, and drinking water, the vaccinated birds showed no clinical signs and had significant protection efficacy (>80%) against very virulent NDV (Kr005 strain) infection regardless of the administration route employed. The results indicate that the NDRL0901 strain is safe in chickens and can offer protective immunity.

Lateralizing value of unilateral relative ictal immobility in patients with refractory focal seizures--Looking beyond unilateral automatisms

PURPOSE

Ictal motor phenomena play a crucial role in the localization of seizure focus in the management of refractory focal epilepsy. While the importance of unilateral automatisms is well established, little attention is paid to the contralateral relatively immobile limb. In cases where automatisms mimic clonic or dystonic movements and in the absence of previously well-established signs, unilateral relative ictal immobility (RII) is potentially useful as a lateralizing sign. This study was carried out to examine the lateralizing value of this sign and to define its characteristics among patients of refractory focal epilepsy.

METHODS

VEEGs of 69 consecutive patients of refractory focal epilepsy who had undergone epilepsy surgery at our center over last four years were reviewed and analyzed for the presence of RII. Unilateral RII was defined as a paucity of movement in one limb lasting for at least 10s while the contralateral limb showed purposive or semi-purposive movements (in the absence of tonic or dystonic posturing or clonic movements in the involved limb). The findings were seen in the light of VEEG, radiological and nuclear imaging data, and with post-surgical outcome.

RESULTS

Unilateral RII as a lateralizing sign was found in 24 of 69 patients (34.78%), consisting of both temporal and extra temporal epilepsy, with 100% concordance with VEEG and MRI data. All patients demonstrating this sign had a good post-surgical outcome.

CONCLUSION

RII, when well characterized is a frequent and reliable lateralizing sign in patients of refractory focal epilepsy.

Posterior circulation aneurysms: A 10-year institutional analysis

Aneurysms are uncommon and challenging to manage.

A retrospective study was designed to report 53 patients who are treated from June 2002 to June 2011.

The mean age at presentation was 46.34 ± 13.67 years (males, 26). Clinical features included subarachnoid hemorrhage (median Hunt and Hess Grade II, n = 42), cranial nerve palsies (9), hydrocephalus (5), and incidentally diagnosed (5). Locations included superior cerebellar artery (3), posterior cerebral artery (2), basilar trunk (4), vertebral (8), anterior inferior cerebellar artery (AICA) (5), posterior inferior cerebellar artery (PICA) (13), vertebrobasilar junction (6), and basilar top (13). Management included both endovascular intervention (26) and surgery (19), and both (2). Five patients presented as poor grade and underwent only extraventricular drain placement while one patient had thrombosed aneurysm and was managed conservatively. Mortality was 26.4% (n = 14) and morbidity included vasospasm (10), meningitis (2), pseudomeningocele (2), pneumonitis (2), and myocardial infarction (1).

Posterior circulation aneurysms are highly challenging. They require the multimodality approach, and decision regarding surgery or embolization has to be individualized.

Efficacy of minocycline in acute ischemic stroke: a single-blinded, placebo-controlled trial

BACKGROUND

Minocycline is a semisynthetic derivative of the tetracycline group of antibiotics, which have neuroprotective effects. In animal stroke models, minocycline had shown promising evidence to improve clinical and functional outcomes.

OBJECTIVE

To analyze the effect of oral minocycline in acute ischemic stroke patients.

MATERIALS AND METHODS

This was a randomized single-blinded open-label study. The study group received oral minocycline 200 mg/day for 5 days and the control group received oral vitamin B capsules. Baseline assessment included the following: National Institute of Health Stroke Scale (NIHSS) score, modified Barthel Index (mBI), modified Rankin Scale (mRS) score, Magnetic Resonance Imaging (MRI) of brain including Diffusion Weighted Imaging (DWI), chest X-ray, and routine laboratory investigations. The clinical scales were repeated at days 1, 7, and 30. The end point was outcomes at 3 months (90 days). Statistical analysis was done with SPSS 11.5 (P<0.05). Paired t-test and multiple-measures Analysis Of Variance (ANOVA) were used.

RESULTS

Fifty patients with acute ischemic stroke were included in the study. Of these, 23 patients received minocycline and 27 patients received placebo i.e., vitamin B capsules. NIHSS score in patients receiving minocycline had shown statistically significant improvement at day 30 and 90 as compared with the controls. Similarly, mRS scores and BI showed significant improvement in patients receiving minocycline at three months as compared to the control group. No mortality, myocardial infarctions, recurrent strokes, and hemorrhagic transformations were noted in both groups.

CONCLUSIONS

Patients with acute ischemic stroke had significantly better outcome with minocycline treatment as compared with those administered placebo. The above findings suggest that minocycline can be helpful in reducing the clinical deficits after acute ischemic stroke.

Evaluation of eperisone hydrochloride in the treatment of acute musculoskeletal spasm associated with low back pain: a randomized, double-blind, placebo-controlled trial

BACKGROUND

Eperisone hydrochloride is a centrally acting muscle relaxant inhibiting the pain reflex pathway, having a vasodilator effect.

AIMS

To evaluate the efficacy and tolerability of eperisone in patients with acute musculoskeletal spasm associated with low back pain.

SETTINGS AND DESIGN

Prospective, randomized, double-blind, placebo-controlled, multicentric trial conducted at five tertiary care orthopedic centers across India.

MATERIALS AND METHODS

It was planned to enroll 240 patients of either sex between 18-60 years with acute musculoskeletal spasm (AMSP) with low back pain (LBP) due to spondylosis deformans, prolapsed disc or muscle sprain. Patients with other associated unrelated spasm conditions were excluded. Assessments were done for finger-to-floor distance (FFD), lumbar pain, Lasegue's sign, tenderness of vertebral muscles, need for rescue medication and response to therapy for efficacy and tolerability.

STATISTICAL ANALYSIS

Parametric data were analyzed by 't' test and ANOVA, and non-parametric data were analyzed using Mann-Whitney 'U' test and Kruskall-Wallis test. Proportions were compared using Fischer's (Chi-square) test.

RESULTS

Two hundred and forty patients were randomized to receive eperisone 150 mg/day in three divided doses (n=120) or placebo (n=120) for 14 days, of which 15 patients did not complete and 225 patients completed the study (eperisone, 112 and placebo, 113). Significantly greater improvement in FFD (P<0.001) from baseline on Day 14 was seen with eperisone (150.66 to 41.75) compared to placebo (138.51 to 101.60). Improvements in other parameters were greater with the eperisone group. For 89 (79.46%) patients the therapy was rated as good-excellent with eperisone compared to 43 (38.05%) patients with placebo. Nausea, abdominal pain, headache and dizziness were the common adverse events with both therapies. Rescue drug was needed by 40 (35.71%) eperisone patients and 83 (73.45%) placebo patients.

CONCLUSIONS

Eperisone hydrochloride was effective and well tolerated for the treatment of patients with AMSP with LBP.

August 2002: 21-year-old male with cystic intracerebral tumor

The August 2002 COM. A 21-year-old male presented with a single episode of generalized tonic clonic seizures. Radiology revealed a cystic tumor with mural nodule suggestive of a pilocytic astrocytoma. However, histopathological examination and electron microscopy revealed features of an intracerebral schwannoma. Therefore, although rare, in an intracerebral cystic lesion with mural nodule, the possibility of an intracerebral schwannoma should be entertained. This is important because this is a benign tumor with favourable response to resection.

Epilepsy surgery in a pediatric population: a retrospective study of 129 children from a tertiary care hospital in a developing country along with assessment of quality of life

PURPOSE

To assess the outcome of a pediatric population operated for drug-resistant epilepsy from a large tertiary care center in India.

METHODS

Retrospectively: quality of life (QOL); prospectively: preoperative assessment included interictal EEG, MRI (as per epilepsy protocol), video-EEG. Ictal SPECT (with subtraction) and PET were performed when required. QOL scores were assessed using the HASS or SSQ for seizure severity, Quality of Life in Childhood Epilepsy (QOLCE) for QOL, and Child Behavior Check List (CBCL) for behavior.

RESULTS

142 were operated from January 2000 to June 2011 by the senior author. 118 patients with at least 1 year of follow-up were included in the study. Mean age at surgery was 9.8 ± 4.3 years. In addition, 40 patients underwent QOL assessment prospectively both before and after surgery. Mean duration of epilepsy was 5.3 ± 3.3 years. A class I outcome (Engel's) was seen in 79.5% patients, class II in 8.6%, class III in 10.7%, and class IV in 1 patient. As per surgical procedures, class I outcome in patients who underwent temporal resection, hemispherotomy and extratemporal resection was 76, 87 and 72%, respectively. QOL scores correlated with duration of seizures, epileptic encephalopathy and outcome of surgery, but not with side of surgery, age and sex.

CONCLUSIONS

This study, the largest reported from India, has demonstrated satisfactory results for epilepsy surgery in children.

Autologous mesenchymal stem cells in chronic stroke

BACKGROUND

Cell transplantation is a 'hype and hope' in the current scenario. It is in the early stage of development with promises to restore function in chronic diseases. Mesenchymal stem cell (MSC) transplantation in stroke patients has shown significant improvement by reducing clinical and functional deficits. They are feasible and multipotent and have homing characteristics. This study evaluates the safety, feasibility and efficacy of autologous MSC transplantation in patients with chronic stroke using clinical scores and functional imaging (blood oxygen level-dependent and diffusion tensor imaging techniques).

METHODS

Twelve chronic stroke patients were recruited; inclusion criteria were stroke lasting 3 months to 1 year, motor strength of hand muscles of at least 2, and NIHSS of 4-15, and patients had to be conscious and able to comprehend. Fugl Meyer (FM), modified Barthel index (mBI), MRC, Ashworth tone grade scale scores and functional imaging scans were assessed at baseline, and after 8 and 24 weeks. Bone marrow was aspirated under aseptic conditions and expansion of MSC took 3 weeks with animal serum-free media (Stem Pro SFM). Six patients were administered a mean of 50-60 × 10(6) cells i.v. followed by 8 weeks of physiotherapy. Six patients served as controls. This was a non-randomized experimental controlled trial.

RESULTS

Clinical and radiological scanning was normal for the stem cell group patients. There was no mortality or cell-related adverse reaction. The laboratory tests on days 1, 3, 5 and 7 were also normal in the MSC group till the last follow-up. The FM and mBI showed a modest increase in the stem cell group compared to controls. There was an increased number of cluster activation of Brodmann areas BA 4 and BA 6 after stem cell infusion compared to controls, indicating neural plasticity.

CONCLUSION

MSC therapy aiming to restore function in stroke is safe and feasible. Further randomized controlled trials are needed to evaluate its efficacy.

Electrophysiological characteristics of seizure clusters

The phenomenon of temporal clustering of seizures is well known, but its effect on seizure localization has not been rigorously analyzed. The aim of our study was to assess electrophysiological localization during Video EEG (VEEG) monitoring in patients with intractable epilepsy demonstrating a cluster of seizures. The study was conducted on 203 intractable epilepsy patients, aged 2 to 60 years (19.96 +/- 10.87). Patients with unilateral temporal lobe epilepsy having clusters were compared with patients not having clusters, and the effect of clustering on concordance was addressed. Fully consistent localization was observed in 116 patients, partially consistent localization in 18 patients, and inconsistent localization in 19 patients. ANOVA did not reveal any significant difference in these groups (p=0.65). A total of 770 seizures recorded from 149 patients was analyzed for clustering effect. Clustering was present in 603/770 seizures pairs (78.31%). In the cluster group, 483 (80.09%) seizure pairs were concordant for seizure onset, while 98 (16.25%) were discordant and 22 (3.65%) were indeterminate. In the noncluster group, 134 (80.24%) seizure pairs were concordant for seizure onset, while 23 (13.77%) were discordant and 10 (5.98%) were indeterminate. The study found that cluster seizures occurring within an interseizure interval (ISI) less than 8 hours are independent and have the same localizing value as those seizures with longer ISIs.

Surgery for medically intractable epilepsy due to postinfectious etiologies

Medically intractable epilepsy (MIE) resulting from postinfectious etiologies requiring surgery have been uncommonly reported. A series of 28 cases are presented (hospital prevalence 5.7%). The mean duration of epilepsy prior to surgery was 8.2 +/- 2.1 years. The mean time of onset of epilepsy after central nervous system infection was 1.4 +/- 0.9 years (range 0-19 years). The pathologies included postpyogenic meningitic/encephalitic sequel (8), neurocysticercosis (6), tuberculomas/posttuberculous etiology (4), postpyogenic abscess of otogenic etiology (4), posttraumatic abscess-related gliosis (2), and gliosis of unknown infectious etiology (4) cases. Surgery included mesial temporal (11), lateral temporal (4), frontal (9), parietal (2) resections and hemispherotomy (1). Hippocampal sclerosis was seen in nine cases (4 neurocysticercosis) and this occurred in younger persons as compared to neocortical epilepsies. Good outcome (Engel class I and II) was seen in 23 of 28 cases (Engel class I in 17).

Intra-operative electrocorticography in lesional epilepsy

Intra-operative electrocorticography (ECoG) is useful in epilepsy surgery to delineate margins of epileptogenic zone, guide resection and evaluate completeness of resection in surgically remediable intractable epilepsies. The study evaluated 157 cases (2000-2008). The preoperative evaluation also included ictal SPECT (122) and PET in 32 cases. All were lesional cases, 51% (81) of patients had >1 seizure/day and another 1/3rd (51) had >1/week. Pre and post resection ECoG was performed in all cases. A total of 372 recordings were performed in 157 cases. Second post-operative recordings (42) and third post-operative recordings (16) were also performed. Site of recordings included lateral temporal (61), frontal (39), parietal (37), hippocampal (16) and occipital (4). 129/157 cases (82%) showing improvement on ECoG, 30/42 cases showed improvement in 2nd post resection, 8/16 showed improvement in the 3rd post-operative ECoG. 116/157 (73%) patients had good outcome (Engel I and II) at follow up (12-94 months, mean 18.2 months). Of these, 104 patients (80%) showed improvement on post-operative ECoG. 12 had good outcome despite no improvement on ECoG. The improvement in ECoG correlated significantly with clinical improvement [Sensitivity: 100% (95% CI; 96-100%); specificity: 68.3% (95% CI; 51.8-81.4%); positive predictive value: 89.9% (95% CI, 83.1-94.3%); negative predictive value: 100% (95% CI, 85-100%)]. The level of agreement was 91.72% (kappa: 0.76). Concluding, pre and post resection ECoG correlated with its grade of severity and clinical outcome.

Spatial characterization of electric potentials generated by pulsed microelectrode arrays

This presentation is a report on the in situ characterization of stimulating microelectrodes in the context of multielectrode retinal prosthetic implants. The experimental system approximately replicates the geometric and electrical parameters of Second Sight Medical Products' Argus II Retinal Implant. Topographic maps of electric potentials have been prepared for a 60 electrode structure in which selected electrodes were stimulated with biphasic repetitively pulsed charge densities at 100 microC·cm(-2). Surface contour maps were prepared using a 10 microm diameter recording electrode.

Surgical outcome of cortical dysplasias presenting with chronic intractable epilepsy: a 10-year experience

BACKGROUND

There has been sparse description of cortical dysplasias (CDs) causing intractable epilepsy from India.

AIM

Clinical retrospective study of CDs causing intractable epilepsy that underwent surgery.

MATERIALS AND METHODS

Fifty-seven cases of CDs reviewed (1995 till July 2006) are presented. All patients had intractable epilepsy, and underwent a complete epilepsy surgery workup (inter ictal electroencephalography (EEG), video EEG, MRI as per epilepsy protocol, SPECT {interictal, ictal with subtraction and co-registration when required}, and PET when necessary). Surgical treatment included a wide exposure of the pathology with a detailed electrocorticography under optimal anesthetic conditions. Mapping of the sensori-motor area was performed where indicated. Procedures included resection either alone or combined with multiple subpial transactions when extending into the eloquent areas.

RESULTS

Our study had 28 (49.12%) cases of isolated focal CDs, and 29 (50.67%) with dual pathology. Average age at the time of onset of seizures in our series was 7.04 years (three months to 24 years), and average age at the time of surgery was 10.97 years (eight months to 45 years). Among coexistent pathologies, one had associated MTS, 16 had coexistent gangliogliomas and 12 (dysembryonic neuroepithelial tumor) DNTs. At an average follow-up of 3.035 years (range 5-10 years), three patients were lost to follow-up. Fifty-one per cent (29/57) patients had a good outcome (Engel Grade I) and 26%(15/57) had a Grade II outcome.

CONCLUSION

Cortical dysplasias have a good outcome if evaluated and managed with concordant electrical and imaging modalities.

Measurement of peak CSF flow velocity at cerebral aqueduct, before and after lumbar CSF drainage, by use of phase-contrast MRI: utility in the management of idiopathic normal pressure hydrocephalus

OBJECTIVE

Since it was first described, normal pressure hydrocephalus (NPH) and its treatment by means of cerebrospinal fluid (CSF) shunting have been the focus of much investigation. Whatever be the cause of NPH, it has been hypothesized that in this disease there occurs decreased arterial expansion and an increased brain expansion leading to increased transmantle pressure. We cannot measure the latter, but fortunately the effect of these changes (increased peak flow velocity through the aqueduct) can be quantified with cine phase-contrast magnetic resonance imaging (MRI). This investigation was thus undertaken to characterize and measure CSF peak flow velocity at the level of the aqueduct, before and after lumbar CSF drainage, by means of a phase-contrast cine MRI and determine its role in selecting cases for shunt surgery.

PATIENTS AND METHODS

37 patients with clinically suspected NPH were included in the study. Changes in the hyperdynamic peak CSF flow velocity with 50 ml lumbar CSF drainage (mimicking shunt) were evaluated in them for considering shunt surgery.

RESULTS

14 out of 15 patients who were recommended for shunt surgery, based on changes peak flow velocity after lumbar CSF drainage, improved after shunt surgery. None of the cases which were not recommended for shunt surgery, based on changes in CSF peak flow velocity after lumbar CSF drainage, improved after shunt surgery (2 out of 22 cases).

CONCLUSION

The study concluded that the phase-contrast MR imaging, done before and after CSF drainage, is a sensitive method to support the clinical diagnosis of normal pressure hydrocephalus, selecting patients of NPH who are likely to benefit from shunt surgery, and to select patients of NPH who are not likely to benefit from shunt surgery.

Giant mucoceles of the frontal sinus: a series and review

Giant mucoceles of the frontal sinus are a rare pathology but their recognition is important in the differential diagnosis of paediatric proptosis and fronto-orbital lesions. Four patients with giant mucoceles of the frontal sinus were retrospectively analyzed. All the patients were females in the paediatric age group presenting with massive cosmetically unacceptable bony swelling in the frontal region along with unilateral extra-axial proptosis. Radiological imaging revealed giant mucoceles of the frontal sinus with extracranial, orbital and anterior cranial fossa extension. One patient had co-existent craniofacial fibrous dysplasia. Single stage surgery was performed in three patients and two-stage surgery in one. Fronto-orbital craniotomy, removal of the posterior wall of the sinus, obliteration of the sinus and its ostium, dural repair and remodeling cranioplasty were performed. Histopathological examination revealed mucoceles in all, and co-existant fibrous dysplasia in one patient. All the patients made excellent cosmetic recoveries with complete resolution of their visual symptoms. Their clinical presentation, radiological manifestations and treatment modalities are analyzed and an extensive review of the literature is presented. Our case of giant frontal mucocele associated with fibrous dysplasia is furthermore the first such report in the existing medical literature.