Childhood-Onset Myopathy With Preserved Ambulation Caused by a Recurrent ADSSL1 Missense Variant

Background and Objectives

Distal myopathies are a heterogeneous group of primary muscle disorders with recessive or dominant inheritance. ADSSL1 is a muscle-specific adenylosuccinate synthase isoform involved in adenine nucleotide synthesis. Recessive pathogenic variants in the ADSSL1 gene located in chromosome 14q32.33 cause a distal myopathy phenotype. In this study, we present the clinical and genetic attributes of 6 Indian patients with this myopathy.

Methods

This was a retrospective study describing on Indian patients with genetically confirmed ADSSL1 myopathy. Details were obtained from the medical records.

Results

All patients presented in their first or early second decade. All had onset in the first decade with a mean age at presentation being 17.7 ± 8.4 years (range: 3-27 years) and M:F ratio being 1:2. The mean disease duration was 9.3 ± 5.2 years ranging from 2 to 15 years. All patients were ambulant with wheelchair bound state in 1 patient due to respiratory involvement. The median serum creatine kinase (CK) level was 185.5 IU/L (range: 123-1564 IU/L). In addition to salient features of ptosis, cardiac involvement, bulbar weakness, and proximo-distal limb weakness with fatigue, there were significant seasonal fluctuations and decremental response to repetitive nerve stimulation, which have not been previously reported. Muscle histopathology was heterogenous with the presence of rimmed vacuoles, nemaline rods, intracellular lipid droplets along with chronic myopathic changes. Subtle response to pyridostigmine treatment was reported. While 5 of 6 patients had homozygous c.781G>A (p.Asp261Asn) variation, 1 had homozygous c.794G>A (p.Gly265Glu) in ADSSL1 gene.

Discussion

This study expands the phenotypic spectrum and variability of ADSSL1 myopathy with unusual manifestations in this rare disorder. Because the variant c.781G>A (p.Asp261Asn) is the most common mutation among Indian patients similar to other Asian cohorts, this finding could be useful for genetic screening of suspected patients.

Delineating the Spectrum of Pituitary Adenoma Based on the WHO 2017 Classification

BACKGROUND

The WHO 2017 classification of endocrine tumors incorporates lineage-specific transcription factors (TF) and hormone expression for the classification of pituitary adenoma (PA). There is paucity of reports describing the spectrum of PA based on this classification.

OBJECTIVE

The aim of this study was to delineate the spectrum of PA based on WHO 2017 classification of endocrine tumors.

MATERIALS AND METHODS

PA diagnosed in the year 2018 were studied. H and E and hormonal immunohistochemistry (IHC) for GH, PRL, ACTH, TSH, FSH, LH, CK, T-Pit and MIB-1 were performed and the results were analyzed.

RESULTS

The cohort included 88 cases. M: F ratio was 2:1. Clinically, 22 (25%) were functional and 66 (75%) were non-functional adenomas. Amongst the clinically functional adenomas, GH secreting adenomas were the commonest (68%). Majority (83%) of non-functional adenomas were hormone positive with gonadotroph adenomas being the commonest (72.7%). Eleven (12.5%) PA were clinically and hormonally silent. Three of these showed intense nuclear T-Pit positivity, classifying them under silent corticotroph adenoma. Lineage of the remaining eight adenomas remained undetermined, since, IHC for Pit-1 and SF-1 was not performed. The aggressive adenomas identified by IHC included sparsely granulated somatotroph adenoma, Crooke cell adenoma, silent corticotroph adenoma, densely granulated lactotroph adenoma in men and constituted 17% of the PA. Four (4/88) cases were clinically invasive.

CONCLUSION

A large majority of PA including aggressive adenomas can be identified by IHC. Addition of T-Pit helped to identify silent corticotroph adenoma. Pit -1 and SF-1 TF would help identify plurihormonal Pit-1 PA and null cell adenomas.

Primary diffuse leptomeningeal primitive neuroectodermal tumor presenting as chronic meningitis

Primary diffuse leptomeningeal primitive neuroectodermal tumor is a rare meningeal neoplasm which can masquerade as chronic meningitis. While the clinical presentation and radiological features may provide a clue to this condition, meningeal biopsy is essential to clinch the diagnosis. A high index of suspicion and a low threshold for re-evaluating cases of neuroinfection that do not respond to empirical therapy are essential in this scenario. We present the case of a nine year old boy who was initiated on antituberculous treatment for chronic meningitis with hydrocephalus. Meningeal biopsy revealed a primary diffuse leptomeningeal primitive neuroectodermal tumor.

Neuromuscular disease genetics in under-represented populations: increasing data diversity

Neuromuscular diseases (NMDs) affect ∼15 million people globally. In high income settings DNA-based diagnosis has transformed care pathways and led to gene-specific therapies. However, most affected families are in low-to-middle income countries (LMICs) with limited access to DNA-based diagnosis. Most (86%) published genetic data is derived from European ancestry. This marked genetic data inequality hampers understanding of genetic diversity and hinders accurate genetic diagnosis in all income settings. We developed a cloud-based transcontinental partnership to build diverse, deeply-phenotyped and genetically characterized cohorts to improve genetic architecture knowledge, and potentially advance diagnosis and clinical management. We connected 18 centres in Brazil, India, South Africa, Turkey, Zambia, Netherlands and the UK. We co-developed a cloud-based data solution and trained 17 international neurology fellows in clinical genomic data interpretation. Single gene and whole exome data were analysed via a bespoke bioinformatics pipeline and reviewed alongside clinical and phenotypic data in global webinars to inform genetic outcome decisions. We recruited 6001 participants in the first 43 months. Initial genetic analyses 'solved' or 'possibly solved' ∼56% probands overall. In-depth genetic data review of the four commonest clinical categories (limb girdle muscular dystrophy, inherited peripheral neuropathies, congenital myopathy/muscular dystrophies and Duchenne/Becker muscular dystrophy) delivered a ∼59% 'solved' and ∼13% 'possibly solved' outcome. Almost 29% of disease causing variants were novel, increasing diverse pathogenic variant knowledge. Unsolved participants represent a new discovery cohort. The dataset provides a large resource from under-represented populations for genetic and translational research. In conclusion, we established a remote transcontinental partnership to assess genetic architecture of NMDs across diverse populations. It supported DNA-based diagnosis, potentially enabling genetic counselling, care pathways and eligibility for gene-specific trials. Similar virtual partnerships could be adopted by other areas of global genomic neurological practice to reduce genetic data inequality and benefit patients globally.

A novel biallelic frameshift variant in C2orf69 causing developmental regression, seizures, microcephaly, autistic features, and hypertonia

Combined oxidative phosphorylation deficiency type 53 (COXPD53) is an autosomal recessive neurodevelopmental disorder (NDD) caused by homozygous variants in the gene C2orf69. Here, we report a novel frameshift variant c.187_191dupGCCGA, p.D64Efs*56 identified in an individual with clinical presentation of COXPD53 with developmental regression and autistic features. The variant c.187_191dupGCCGA, p.D64Efs*56 represents the most N-terminal part of C2orf69. Notable clinical features of COXPD53of the proband include developmental delay, developmental regression, seizures, microcephaly, and hypertonia. Structural brain defects of cerebral atrophy, cerebellar atrophy, hypomyelination, and thin corpus callosum were also observed. While we observe strong phenotypic overlap among affected individuals with C2orf69 variants, developmental regression and autistic features have not been previously described in individuals with COXPD53. Together, this case expands the genetic and clinical phenotypic spectrum of C2orf69-associated COXPD53.

Non-granulomatous inflammatory lesions of CNS: Approach to diagnosis

Infections constitute an important and common category of diseases, particularly in less developed countries. Infections present with a broad spectrum of clinical and radiologic features dictated by the cell and tissue tropism and host response elicited, posing a considerable diagnostic challenge. Early diagnosis and treatment are crucial in preventing mortality and morbidity. Recourse is often made to biopsy for ascertaining the diagnosis, and hence the pathologist plays a vital role in patient management. Therefore, knowledge of the histopathologic changes is necessary to recognize the histological changes and guide the diagnostic workup and management. Each microbial agent elicits a distinctive pattern of inflammatory tissue response, which can serve as a clue to the etiological agent. Based on the causative organism, microbial, and host factors, the inflammatory response may be acute or chronic, necrotic or non-necrotic. The inflammation can be of varied patterns - lymphohistiocytic, granulomatous, inflammatory demyelinating, fibrosing, or showing minimal inflammation. The pattern of necrosis also differs based on the causative organism. Typically, pyogenic bacteria are associated with suppurative inflammation, tuberculosis with caseous granulomatous, and fungi with suppurative granulomatous inflammation. Viral infections are associated with lymphohistiocytic non-necrotizing inflammation and, based on cell tropism, can cause demyelination (e.g., JCV) and/or viral inclusions. Parasitic infections (protozoal or metazoal) display a broad spectrum of inflammatory changes that overlap with other types of infections. This review briefly describes pathological patterns and associated pathogens and provides an algorithmic approach based on pattern recognition that may be useful for the practicing pathologist.

Gamut of Orbital Lesions in a Tertiary Neurocenter-A Clinicopathological Study of Lesions Seen Over a Period of One Decade

BACKGROUND

The orbital region is an anatomically complex area comprising crucial contiguous/adjacent structures. Since the eye has a neuroectodermal basis of embryogenesis, many of the lesions may be similar to those arising in the central nervous system.

OBJECTIVE

To record and describe the clinicopathological spectrum of orbital lesions presenting to a neurology center.

STUDY SETTING

The retrospective study included biopsy/resected specimens of patients with orbital/ophthalmic lesions referred to the Department of Neuropathology, between February 2007 and February 2018.

MATERIALS AND METHODS

: The demographic, clinical, and radiological details were retrieved from the departmental archives and the slides were reviewed.

RESULTS

There were 99 cases in the period of the study (2007-2018) with a peak in fourth and fifth decades (age range: 5 months to 68 years; mean: 37.2 years; M: F =1.06: 1). Eighty-six (86.8%) cases had epicenter in the orbit, whereas 13 (13.13%) cases were extraorbital with orbital extension. The benign neoplasms predominated (50/99, 50.5%) followed by malignant neoplasms (24/99, 24.24%), infective conditions (11/99, 11.11%) and tumor like conditions (7/99, 7.07%). The most common benign tumor was vascular tumor (17/50, 34%) followed by meningioma (12/50, 24%), while epithelial malignant tumor (6/24, 25%) was the most common malignancy. Fungal infection was the most frequent infective condition (6/11, 54.5%).

CONCLUSION

The spectrum of ocular-orbital lesions varies with the geographic area and the nature of the institute catering to the needs of patients. The spectrum of lesions that we encountered from a neurological institute was vastly different from that reported from ophthalmic centers with very low frequency of retinoblastomas.

Basic requirements to establish a neuromuscular laboratory

Histopathological analysis of muscle biopsy is a prerequisite in the evaluation of neuromuscular disorders, particularly inflammatory myopathies, metabolic myopathies, congenital myopathies, muscular dystrophies and differentiating myopathies and neurogenic disorders with overlapping clinically features. It not only provides useful information that helps in the diagnosis but also treatment and management. Fundamental skills and basic knowledge regarding handling, processing and analyzing a muscle biopsy are required in any specialized or a general pathology lab supporting neuromuscular clinical services. Care during transport of the muscle biopsy, sample receipt in the laboratory and grossing is very important. Standard operating procedure should be followed for the preanalytical steps (freezing and cryomicrotomy), routine and special staining (enzyme and non enzymatic) and immunohistochemistry. A well organized neuromuscular laboratory with good quality management system is necessary for the practice of myopathology. This article gives an overview of establishing such a laboratory.

Vogt-Koyanagi-Harada Syndrome - A Neurologist's Perspective

Vogt-Koyanagi-Harada (VKH) syndrome is an immune-mediated granulomatous disease which affects melanin-rich organs like eyes, skin, nervous system, and ears. Neurological and auditory manifestations usually precede the involvement of other sites. Patients may manifest with “complete” or “incomplete” syndrome. We report two patients who presented with acute headache and impaired vision. Fundus examination revealed optic disc hyperemia and exudative retinal detachment which provided a clue for the diagnosis at the bedside. Fundus fluorescein angiogram (FFA) revealed abnormal dye leakage, whereas B scan showed choroid thickening. Cerebrospinal fluid (CSF) pleocytosis contrasted with unremarkable brain magnetic resonance imaging and lack of meningeal signs. Melanophagocytosis was evidenced by melanin-laden macrophages in CSF and skin biopsy. This finding is specific for VKH syndrome and helps to clinch the diagnosis even when the complete syndrome is not present cross-sectionally. VKH syndrome should be suspected in patients with aseptic meningitis if tests for common infectious and immune-mediated diseases are negative.

The risks factor of recurrence after skull base hemangiopericytoma management: A retrospective case series and review of literature

OBJECTIVES

Skull base hemangiopericytomas are rare malignant meningothelial tumors involving anterior, middle, and posterior cranial fossa. The outcome of these tumors is inferior due to aggressive behavior and local recurrence. The study aimed to find out the factors affecting the early recurrence and the late recurrence.

METHODOLOGY

A retrospective study was performed over 15 years, and patients were included from a single neurosurgical unit. A total of 35 patients were recruited for analysis.

RESULTS

Twenty-five (71.4%) cases were in the posterior fossa, four (11.4%) cases in the middle cranial fossa, and three (8.6%) patients in the anterior cranial fossa. Fourteen (40%) cases underwent gross total excision, 21(60%) cases subtotal excision. Follow up available for 32 patients, and the median follow -up duration was 64 months (6-240 months). Progression-free survival for the gross total resection group was 104 months compared to 60 months for subtotal resection (p = 0.07). Nineteen (54.3%) cases had recurrence during follow- up period. Six (17.1%) cases recurrence at 1-year time, five (14.3%) cases at 3-year time, three (8.6%) at 5-yr time, four (11.4%) cases at 10- year time. Seventeen (48.6%) cases received radiotherapy, and 13 cases underwent re-exploration and excision of the tumor. Univariate ordinal logistic regression showed that the extent of resection was associated with 1-year, 3-year and 5-year recurrence. Multivariate ordinal logistic regression showed that only extent of resection (STR) was associated with both early and late recurrence.

CONCLUSIONS

The extent of resection is the main predictor of early and delayed recurrence. Upfront radiation therapy has superior tumor control in skull base location.

Distal anterior cerebral artery aneurysm with bilateral fetal posterior cerebral arteries and trifurcation of anterior cerebral artery

Developmental vascular anomalies of brain are non-modifiable risk factors for the development of aneurysms and are prone for rupture. We report one such association in a 44-year-old gentleman who succumbed to subarachnoid hemorrhage (SAH) secondary to ruptured distal anterior cerebral artery aneurysm associated with vascular anomalies in the anterior and posterior circulation that included trifurcation of anterior cerebral artery and bilateral fetal posterior cerebral arteries. We identified multiple anomalies in circle of Willis that could have contributed to the formation of aneurysm and early rupture. Knowledge of these variations is essential to plan early and optimum management with close follow-up.

Diagnostic Utility of CUSA Specimen in Histopathological Evaluation of Tumors of Central Nervous System

Introduction

Cavitron Ultrasonic Surgical Aspirator (CUSA) is a technique used for the surgical treatment of tumors that aids the surgeon in highly selective tumor sampling with minimal injury to surrounding tissues. The utility of the tissue obtained from CUSA for histopathological diagnosis of central nervous system tumors is not as well-known as its surgical benefits. Even though a few studies have evaluated the diagnostic accuracy of CUSA specimen, these have dealt with very few cases.

Methodology

In this study, we nil analysed 73 cases of CNS tumors (glial and non-glial) where CUSA specimen was available for histopathological examination and compared with findings on conventional samples as gold standard.

Results

Most frequent types of artefacts induced by CUSA included tissue breakdown resembling necrosis, empty spaces in tissues, and crush artefacts particularly in cellular tumors, that interfered with interpretation. CUSA samples were found optimal for diagnosis of non-glial tumors (45/73), (mainly mesenchymal), wherein the diagnostic utility was comparable to the conventional samples. Difficulties were encountered in glial neoplasms, medulloblastomas and meningiomas. In glial neoplasms (28/73), accurate grading was not possible (9/28, 32%) utilising CUSA samples alone as necrosis and mitosis were not represented. Similarly in meningiomas, mitosis and brain invasion, essential for grading, was not recognizable in CUSA samples. In medulloblastomas, extensive crush artefacts interfered with diagnosis and histological subtyping making it mandatory to examine conventional tissue samples and CUSA. Immunohistochemistry results were optimal with CUSA tissue, wherever performed.

Conclusion

The greatest benefits of CUSA, is its ability to sample multiple areas enhancing the yield in heterogenous tumors like gliosarcomas and its utility in tumors at surgically inaccessible sites. As a policy, we recommend that it is beneficial that all surgically excised tissues including those from the CUSA bottle and suction be sent for histopathological analysis for optimising diagnostic accuracy.

Consumption of spine by tuberculosis in the era of directly observed treatment, short-course and genomic diagnosis

BACKGROUND

Extra Pulmonary Tuberculosis (EPTB) is a significant health problem in both developing and developed countries. Spinal tuberculosis (STB) is one of the significant forms of EPTB lacking epidemiological data. The present study was conducted to study the clinical, radiological, microbiological and histopathological features, treatment and outcome of Spinal tuberculosis.

METHODS

This study was conducted for a duration of 19 years, from 2000 to 2018 at the department of Neuromicrobiology, NIMHANS, Bengaluru. It comprised of 252 patients with STB. All patients were diagnosed with the clinical features and confirmed by radiological, microbiological and histopathological findings.

RESULTS

Results were tabulated and statistically studied. The most common age group is 30-40 years with male preponderance. Most patients presented with motor paraplegia/para paresis (99.6%). Thoracic spine was the most common vertebra affected (47.62%). The commonest imaging feature is soft tissue collection (81.74%). Most common histopathological feature was necrotising granulomatous inflammation (65.87%). Microbiology reports showed growth of Mycobacterium tuberculosis (MTB) in 29.76%, Ziehl Neelsen (ZN) smear showed acid fast bacilli (AFB) in 25.79%. Anti tubercular drugs and surgery were advised in 55.55% patients and only anti TB drugs for 39.28%. The entire course of anti tubercular treatment (ATT) was completed in 60.71% and 4.76% were defaulters.

CONCLUSION

Spinal tuberculosis is a global disease, timely diagnosis with clinical, imaging, microbiological, histopathological features and complete course of anti-tubercular treatment along with symptomatic treatment appears to be safe and effective.

Novel variants broaden the phenotypic spectrum of PLEKHG5-associated neuropathies

BACKGROUND AND PURPOSE

Pathogenic variants in PLEKHG5 have been reported to date to be causative in three unrelated families with autosomal recessive intermediate Charcot-Marie-Tooth disease (CMT) and in one consanguineous family with spinal muscular atrophy (SMA). PLEKHG5 is known to be expressed in the human peripheral nervous system, and previous studies have shown its function in axon terminal autophagy of synaptic vesicles, lending support to its underlying pathogenetic mechanism. Despite this, there is limited knowledge of the clinical and genetic spectrum of disease.

METHODS

We leverage the diagnostic utility of exome and genome sequencing and describe novel biallelic variants in PLEKHG5 in 13 individuals from nine unrelated families originating from four different countries. We compare our phenotypic and genotypic findings with a comprehensive review of cases previously described in the literature.

RESULTS

We found that patients presented with variable disease severity at different ages of onset (8-25 years). In our cases, weakness usually started proximally, progressing distally, and can be associated with intermediate slow conduction velocities and minor clinical sensory involvement. We report three novel nonsense and four novel missense pathogenic variants associated with these PLEKHG5-associated neuropathies, which are phenotypically spinal muscular atrophy (SMA) or intermediate Charcot-Marie-Tooth disease.

CONCLUSIONS

PLEKHG5-associated neuropathies should be considered as an important differential in non-5q SMAs even in the presence of mild sensory impairment and a candidate causative gene for a wide range of hereditary neuropathies. We present this series of cases to further the understanding of the phenotypic and molecular spectrum of PLEKHG5-associated diseases.

Clinicopathological Study of Extra-Axial Small Round Cell Tumors of the Cranium

Introduction

The cranium is a host to a variety of neoplasms and includes small round cell tumors (SRCTs) as an important malignant subset. Although SRCTs are histomorphologically similar, they are histogenetically diverse comprising of malignancies of epithelial, hematolymphoid, neuroectodermal, and mesenchymal origin.

Objective

The study aimed to review the clinical and pathological profile of cranial SRCTs.

Materials and Methods

Study is a retrospective review (clinical, imaging, and histopathology) of cranial (extra-axial) SRCTs diagnosed on histology (period: 3.5 years).

Results

Study included 126 cases constituting 1.5% of all intracranial neoplasms and age ranging from 11 months to 82 years (mean: 34.3 years; M:F = 1.46:1). Peripheral primitive neuroectodermal tumors (pPNET-8.2%) was the commonest neoplasm followed by plasmacytoma (14.2%), poorly differentiated carcinomas (13.5%), lymphomas (9.5%), and sarcomas (8.7%). Rare tumors included glioma (undifferentiated) deposits, germ cell tumors, melanoma, neuroendocrine neoplasms, and embryonal tumor. Children constituted one-third of the total with PNETs, embryonal tumors, and round cell sarcomas being the common neoplasms. Elderly patients constituted 14% with plasmacytomas and epithelial neoplasms being common. Three percent of the tumors remained unclassified. Clinical symptomology was location dependent, headache being the commonest followed by visual symptoms. Radiopathological discordance was high (60%).

Conclusion

SRCTs are unusual tumors with a wide spectrum of histogenesis, biology and clinical presentation. Their rarity in cranium, atypical localization, overlapping clinical, and imaging features pose significant difficulty for clinicians, radiologists, and pathologists. A combined algorithmic analysis of the clinical, radiological, and histolopathological findings, supplemented with immunohistochemistry can aid in specific diagnosis which is crucial for optimal management.

Rare neurohypophyseal tumor presenting as giant pituitary macroadenoma with cavernous sinus invasion - A case report and review of literature

Background:

Granular cell tumors (GCTs) of the pituitary are rare tumors of posterior pituitary that can present as giant pituitary macroadenoma due to the slow indolent growth of the tumor. We are reporting this case due to the rarity of GCT and usually these tumors are confined to the suprasellar region since they are arising from the pituitary stalk. GCTs that attain such giant size with cavernous sinus invasion are still rarer.

Case Description:

A 38-year-old female who presented with progressive deterioration of vision and on evaluation by magnetic resonance imaging showed a giant pituitary macroadenoma with bilateral cavernous sinus invasion. The patient underwent pterional craniotomy and near-total excision of the lesion was done due to high vascularity and firmness of the tumor. Histopathology examination of the lesion showed spindle to globular cells with granular cytoplasm and was reported as GCT of the pituitary.

Conclusion:

GCTs are WHO grade1 non-neuroendocrine tumors arising from neurohypophysis and infundibulum. Complete excision is usually difficult due to the high vascularity, firm consistency, and local invasion of the tumor to the cavernous sinus and optic apparatus.

Brain and Spinal Cord Lesions in Leprosy: A Magnetic Resonance Imaging-Based Study

Neurotropism and infiltration by Mycobacterium leprae of peripheral nerves causing neuropathy are well established, but reports of central nervous system (CNS) damage are exceptional. We report CNS magnetic resonance imaging (MRI) abnormalities of the brain and spinal cord as well as lesions in nerve roots and plexus in leprosy patients. Eight patients aged between 17 and 41 years underwent detailed clinical, histopathological, and MRI evaluation. All had prominent sensory-motor deficits with hypopigmented and hypo/anesthetic skin patches and thickened peripheral nerves. All demonstrated M. Leprae DNA in affected peripheral nerve tissue. All received multidrug therapy (MDT). Two patients had brainstem lesions with enhancing facial nuclei and nerves, and one patient had a lesion in the nucleus ambiguus. Two patients had enhancing spinal cord lesions. Follow-up MRI performed in four cases showed resolution of brainstem and cord lesions after starting on MDT. Thickened brachial and lumbosacral plexus nerves were observed in six and two patients, respectively, which partially resolved on follow-up MRI in the two cases who had reimaging. The site and side of the MRI lesions corresponded with the location and side of neurological deficits. This precise clinico-radiological correlation of proximal lesions could be explained by an immune reaction in the gray matter corresponding to the involved peripheral nerves, retrograde axonal and gray matter changes, or infection of the CNS and plexus by lepra bacilli. Further study of the CNS in patients with leprous neuropathy is needed to establish the exact nature of these CNS MRI findings.

Ossified Occipital Pseudomeningocele following Ventriculoperitoneal Shunt Malfunction

Ossification of pseudomeningocele is a rare occurrence and is one of the rare complications of ventriculoperitoneal (VP) shunt malfunction. We report a case of 12-year-old boy who came with features of raised intracranial pressure following shunt malfunction which was placed as a treatment to the aqueductal stenosis. Computed tomography showed ventriculomegaly and hypodense collection in the occiput with posterior rim of calcification. The findings were confirmed on histopathology. Although ossified pseudomeningocele is a rare entity following VP shunt placement, it should be suspected if patients present with aggravated symptoms, especially if there is shunt malfunction as the treatment option varies with the presence or absence of resultant symptoms and ossification.

Isolated Sphenoid Sinus Lesions: Experience with a Few Rare Pathologies

INTRODUCTION

The sphenoid sinus is often neglected because of its difficult access. The deep position of the sphenoid sinus hinders early diagnosis of pathologies in that location. Delayed diagnosis can cause serious complications due to proximity to many important structures.

OBJECTIVES

The aim of this study is to demonstrate different pathologies which can affect the sphenoid sinus and elucidate the findings.

METHODS

Cases of isolated sphenoid sinus lesions encountered in the neurosurgical setting which had rare pathologies are discussed. Pathologies such as Langerhans cell histiocytosis, solitary plasmacytoma, chordoma, pituitary adenoma, leiomyosarcoma, fungal infection, and mucocele which appeared primarily in sphenoid sinus are discussed along with their imaging features and pathological findings.

CONCLUSION

Multitude of different pathologies can occur in sphenoid sinus. Detailed preoperative imaging is very helpful, but transnasal biopsy and histological study are required often for definitive diagnosis. The possible advantages of early diagnosis before spread of pathology for prognosis cannot be overemphasized.

Recurrent Glioblastomas Exhibit Higher Expression of Biomarkers with Stem-like Properties

Background

Despite advances in the treatment of glioblastoma (GBM), the prognosis of patients continues to remain dismal. This unfavorable prognosis is mainly attributed to the tumor's propensity for progression and recurrence, which in turn is due to the highly aggressive nature of the persisting GBM cells that actively egress from the main tumor mass into the surrounding normal brain tissue. Such a recurrent tumor described to have a more malignant potential is highly invasive and resistant to current therapies, probably due to increased stemness and preferential selection of therapy-resistant clones of tumor cells. However, there is a paucity of literature on the expression of biomarkers in the recurrent GBM tumors that could have a role in conferring this aggressiveness.

Aim

To identify the differences in the expression pattern of selected biomarkers in paired tissue samples of GBM.

Material and Methods

A retrospective study on 30 paired samples of GBM (newly diagnosed/primary and recurrent) archived in the Department of Neuropathology, NIMHANS (2006-2009), was carried out. After obtaining clinical and demographic details, tumors were characterized histomorphologically and immunohistochemically on formalin-fixed paraffin-embedded tissues with reference to expression of biomarkers such as p53, epidermal growth factor receptor (EGFR), insulin-like growth factor binding protein 3 (IGFBP-3), sex determining region Y-box 2 (SOX2), and topoisomerase 2 A (Top2A). The results were statistically analyzed.

Results

It was observed that while p53 and IGFBP-3 expression remained unaltered in paired samples, a significant increase in the expression of EGFR (P < 0.01) was noted in the recurrent tumors. Among the other biomarkers, SOX2 expression was higher in the recurrent tumors when compared to the primary tumors (P < 0.01). Conversely, the expression of Top2A was reduced in recurrent tumors (P = 0.05). Mild elevation in the expression of IGFBP-3 was observed in recurrent tumors but was not statistically significant.

Conclusion

A significant increase in the expression of SOX2 in recurrent tumors probably indicates the presence of undifferentiated cells with stem-like properties in these tumors. EGFR is known to mediate SOX2 expression thereby resulting in stemness of the glioma cancer cells, which could further explain its overexpression in recurrent GBMs. Furthermore, a decreased expression of TOP2A observed in the recurrent tumors could probably be due to reduction in chemosensitivity to temozolomide, which has been shown in earlier studies. We also noted that p53 expression remained unaltered in the recurrent tumors when compared to the primary, suggesting the absence of preferential clonal expansion of p53 mutant cells following exposure to radiochemotherapy. Our study reiterates the fact that GBM recurrences are associated with molecular alterations that probably contribute to radiochemoresistance, increased invasiveness, therapeutic efficacy, and stemness.

Supratentorial Pure Cortical Ependymoma: An Unusual Lesion Causing Focal Motor Aware Seizure

Ependymomas usually arise from the ependymal lining cells of the ventricular system and central canal of the spinal cord. Supratentorial ependymoma is a rare entity with the variable clinical course. In a small number of cases, ependymoma arises from supratentorial parenchyma. Only a few cases are reported in the literature. We report a case of 3-year-old girl with left frontal mass. Total removal of the mass lesion was performed without any neurological deficit. Pathological examination of the excised tumor was consistent with anaplastic ependymoma. We have discussed management strategy of this rare entity.

Intracranial fungal granuloma: a single-institute study of 90 cases over 18 years

OBJECTIVE

Intracranial fungal granuloma (IFG) remains an uncommon entity. The authors report a single-institute study of 90 cases of IFG, which is the largest study until now.

METHODS

In this retrospective study, all cases of IFG surgically treated in the years 2001-2018 were included. Data were obtained from the medical records and the pathology, microbiology, and radiology departments. All relevant clinical data, imaging characteristics, surgical procedure performed, perioperative findings, and follow-up data were recorded from the case files. Telephonic follow-up was also performed for a few patients to find out their current status.

RESULTS

A total of 90 cases consisting of 64 males (71.1%) and 26 (28.9%) females were evaluated. The mean patient age was 40.2 years (range 1-79 years). Headache (54 patients) was the most common presenting complaint, followed by visual symptoms (35 patients), fever (21 patients), and others such as limb weakness (13 patients) or seizure (9 patients). Cranial nerve involvement was the most common sign (47 patients), followed by motor deficit (22 patients) and papilledema (7 patients). The mean duration of symptoms before presentation was 6.4 months (range 0.06-48 months). Thirty patients (33.3%) had predisposing factors like diabetes mellitus, tuberculosis, or other immunocompromised status. A pure intracranial location of the IFG was seen in 49 cases (54.4%), whereas rhinocerebral or paranasal sinus involvement was seen in 41 cases (45.6%). Open surgery, that is, craniotomy and decompression, was performed in 55 cases, endoscopic biopsy was done in 30 cases, and stereotactic biopsy was performed in 5 cases. Aspergilloma (43 patients) was the most common fungal mass, followed by zygomycosis (13 patients), chromomycosis (9 patients), cryptococcoma (7 patients), mucormycosis (5 patients), and candida infection (1 patient). In 12 cases, the exact fungal phenotype could not be identified. Follow-up was available for 69/90 patients (76.7%). The mean duration of the follow-up was 37.97 months (range 3-144 months). The mortality rate was 52.2% (36/69 patients) among the patients with available follow-up.

CONCLUSIONS

A high index of suspicion for IFG should exist for patients with an immunocompromised status and diabetic patients with rhinocerebral mass lesions. Early diagnosis, aggressive surgical decompression, and a course of promptly initiated antifungal therapy are associated with a better prognosis.

Atypical presentation of extraspinal neurofibroma presenting with acute-onset monoparesis and Horner's syndrome: Case report and review of literature

The clinical presentation of spinal or extraspinal neurofibroma is radiculopathy or myelopathy, pain, and motor weakness. Extraspinal neurofibroma presenting with acute-onset monoparesis and Horner's syndrome is very rare. We report the case of a 55-year-old female who presented with acute-onset monoparesis of the left upper limb along with left-side drooping of the eyelid. Imaging revealed C6–D2 extraspinal solitary mass lesion lateral to spinous process with bleed without intraspinal component. The patient underwent an anterior cervical approach and excision of the tumor. Final biopsy report was a neurofibroma. At 3-year follow-up, she recovered from motor weakness, and Horner's syndrome subsided. Extraspinal neurofibroma can present with acute bleed, and surgical outcome is superior in early intervention.

Cerebrovascular pathology in cerebral amyloid angiopathy presenting as intracerebral haemorrhage

Cerebral amyloid angiopathy (CAA) is the second most common cause of non-traumatic intracerebral haemorrhage (ICH) accounting for 12-15% of lobar haemorrhages in the elderly. Definitive diagnosis of CAA requires histological evaluation. We aimed to evaluate the spectrum of cerebrovascular changes in CAA-related ICH. Between 2011 and 2015, biopsy-confirmed cases of CAA were retrieved and clinical, radiological and pathological features were reviewed. The spectrum of vascular alterations was evaluated and amyloid deposition was graded in accordance with the Greenberg and Vonsattel scale. Seven cases of sporadic CAA [5 males and 2 females] were diagnosed, none of whom were suspected to have CAA pre-operatively. Six presented with large intracerebral haematoma (ICH) requiring neurosurgical intervention (age range: 56-70 years) and one had episodic headache and multiple microhaemorrhages requiring a diagnostic brain biopsy (45 years). In the presence of large ICH, vascular amyloid deposits were of moderate to severe grade (grade 4 in 4, grades 2 and 3 in 1 case each) with predominant involvement of medium (200-500 μm) to large (> 500 μm) leptomeningeal vessels. Fibrinoid necrosis was noted in four. Two were hypertensive and on antiplatelet agents. β-Amyloid plaques were detected in two, one of whom had symptomatic dementia. MRI performed in 3 of 6 cases with ICH did not reveal any microhaemorrhages. Amyloid deposits in small (50-200 μm) to medium (200-500 μm) calibre intracortical vessels produced parenchymal microhemorrhages. Histopathological examination of ICH is essential for diagnosing CAA. The vascular calibre rather than grade of amyloid deposits dictates size of the bleed. Presence of co-morbidities such as antiplatelet agents may predispose to haemorrhage.

Cervical Spine Osteoblastoma with an Aneurysmal Bone Cyst in a 2-Year-Old Child: A Case Report

Osteoblastomas and aneurysmal bone cysts are uncommon benign tumors of the spine. Their presentation can vary between diffuse pain, restriction of neck movements, torticollis, radiculopathy, and myelopathy. Complete excision is the best treatment to achieve a cure, but recurrence is not uncommon. A combination of the two conditions in the pediatric population is extremely rare. To the best of the authors' knowledge, only 2 cases of such a combination in the cervical spine have been reported in the literature. We report the case of a 2-year-old child having a right C4 lateral mass osteoblastoma with an aneurysmal bone cyst. The child underwent complete surgical excision of the lesion with fusion.

Pediatric Suprasellar Atypical Teratoid Rhabdoid Tumor Arising from the Third Ventricle: A Rare Tumor at a Very Rare Location

Atypical teratoid rhabdoid tumor (ATRT) is a rare, highly malignant tumor of the central nervous system, commonly affecting children below 3 years of age, with around 300 cases reported in the literature. Suprasellar area is a very rare location for such tumor in the pediatric population, with technical difficulties in complete excision. Third ventricular ATRT is very rare. Here, we report the case of a 2-year-old male child who presented with lethargy and vomiting. He had features of raised intracranial pressure with reduced vision in both eyes. Magnetic resonance imaging of the brain revealed a heterogeneously enhancing lobulated giant lesion in the suprasellar location, occupying the third ventricle and hypothalamus with encasement of both carotids. He underwent pericoronal parasagittal craniotomy, interhemispheric transcallosal interforniceal approach and gross total excision of the lesion. Postoperatively, the child had altered sensorium and diabetes insipidus, both of which recovered over a span of 10 days. Histopathological examination of the specimen was consistent with the diagnosis of World Health Organization Grade IV ATRT. In spite of all our efforts, he succumbed to his illness 5 months postoperatively.

Pilocytic astrocytoma with spontaneous malignant transformation with intracranial and skeletal dissemination: case report and review of the literature

Pilocytic astrocytoma is a benign low-grade tumor with a favorable prognosis. We present a 47-year-old- lady with a posterior fossa pilocytic astrocytoma who underwent surgical decompression. She developed multiple early local recurrences Along with malignant transformation of the cranial lesion she developed skeletal dissemination within a very short time frame. There were no features or family history of neurofibromatosis 1. She did not receive radiotherapy or chemotherapy prior to the recurrences.

Primary Pediatric Intracranial Neuroblastoma: A Report of Two Cases

Neuroblastoma is the most common pediatric extracranial solid malignancy. It has a high propensity for spread, especially to the bones and lymph nodes. The involvement of central nervous system is uncommon and most of the cases are restricted to the spine. Primary intracranial neuroblastoma is extremely rare and very few cases have been described in the available literature. We report two cases of primary intracranial neuroblastoma in pediatric age group.

Cerebellopontine Angle Schwannoma and Meningioma in Contiguity: Surgical Implications in Neurofibromatosis

Concurrent occurrence of brain tumors in the same location is very unusual and has been noted in patients with neurofibromatosis. Two lesions, occurring in close contact but of different histology, are called contiguous tumors. Schwannoma and meningioma are the two common histologies reported to present as contiguous tumor. We present two patients with contiguous tumors in the cerebellopontine angle. The magnetic resonance imaging characteristics in both cases demonstrate important findings that should be identified to raise the possibility of contiguous tumors. We discuss the surgical implications in identifying the facial nerve in this complex tumor morphology and steps we took to preserve function. Variable displacement of the facial nerve in the presence of multiple tumors needs to be kept in mind during surgical management and can be significantly aided by intraoperative monitoring.

A simple algorithmic approach using histology and immunohistochemistry for the current classification of adult diffuse glioma in a resource-limited set-up

AIMS

The WHO 2016 classification of diffuse gliomas combines histological and molecular parameters for diagnosis. However, in view of cost constraints for molecular testing, an economical working formula is essential to reach a meaningful diagnosis in a resource-limited setting. The aim of this study was to establish a practical algorithmic approach using histology and immunohistochemistry (IHC) in the classification of diffuse gliomas in such a set-up.

METHODS

Diffuse gliomas of WHO grade II and III diagnosed in our institute in the year 2016 were analysed for histological and IHC features, using the markers isocitrate dehydrogenase 1 (IDH1R132H) and α thalassemia/mental retardation syndrome X-linked gene (ATRX). Fluorescence in situ hybridisation (FISH) for 1p/19q co-deletion was performed when requested.

RESULTS

449 diffuse gliomas (grades II/III) were included in the study. Integrating histology and IHC features, as per the WHO 2016 guidelines, we derived the following groups: Astrocytoma, IDH-mutant (A,IDH-mt, 37.2%); astrocytoma, not otherwise specified (A,NOS, 12.7%); oligoastrocytoma, NOS (OA,NOS, 4.5%); and oligodendroglioma, NOS (ODG,NOS, 45.6%). FISH was performed in a subset of ODG,NOS, OA,NOS and A,NOS gliomas. This revealed 1p/19q co-deletion in all cases of ODG,NOS, 15.8% of OA,NOS and 37.5% of A,NOS. Sequencing for rare IDH 1/2 mutations was not carried out in this study.

CONCLUSION

In a resource-limited set-up, histology with IHC (IDH1(R132H) and ATRX) form the baseline to reasonably derive four histomolecular subgroups of diffuse glioma. Of these, we recommend, OA,NOS and IDH1(R132H)-non-mt ODG,NOS to be our priority for performing 1p/19q co-deletion studies in comparison to IDH-mt ODG,NOS, and it would not be mandatory for astrocytoma. Sequencing for rare IDH mutations is advised for A,NOS and OA,NOS groups, but not for the IDH1(R132H)-non-mutant diffuse gliomas with 1p/19q co-deletion.

Choroid plexus tuberculoma. Diagnosis, management and role of endoscopy

Ventricular involvement in central nervous system tuberculosis can be in the form of tuberculous ependymitis, intraventricular tuberculoma, intraventricular tuberculous abscess, choroid plexitis and choroid plexus tuberculoma. Only a few cases of choroid plexus tuberculomas have been described and even more rare is the description of the role of endoscopy in management of intraventricular tuberculomas. We report a 33-year-old patient while on treatment for tubercular meningitis who developed a left side choroid plexus lesion with loculated temporal horn. To confirm the diagnosis, endoscopic biopsy of the lesion was carried out. The final histopathology was tuberculoma. Intraventricular tuberculomas are usually associated with recalcitrant lesions, probably due to the poor drug levels within the CSF or as an indirect effect of immune resistance and biopsy becomes important to rule out other possibilities.

Spinal epidural capillary hemangioma: A rare case report with a review of literature

Background:

Purely epidural capillary hemangiomas are very rare. There are only 6 such reports.

Case Description:

A 50-year-old male presented with a progressive lower extremity paraparesis. Magnetic resonance imaging demonstrated a purely epidural lesion at the L1-L2 level without any bony involvement. Following an L1-L2 laminectomy for total excision of the lesion, the patient showed significant improvement. The histopathology was consistent with a pure capillary hemangioma.

Conclusion:

The radiological presentation of purely epidural capillary hemangiomas are often similar to those of schwannomas and meningiomas. Surgical confirmation of the pathology, and gross total excision of these lesions is recommended.

Management dilemmas in a rare case of pituitary apoplexy in the setting of dengue hemorrhagic fever

Background:

Pituitary apoplexy occurs due to infarction or hemorrhage, within a pituitary adenoma or a nontumorous pituitary gland and can have catastrophic consequences. Dengue hemorrhagic fever (DHF) is a severe manifestation of the spectrum of dengue virus infection and is characterized by high-grade fever, thrombocytopenia, hemorrhagic tendencies, and increased vascular permeability. Cases of incidentalomas complicated by DHF and presenting with apoplexy are extremely rare.

Case Description:

We describe the case of a 45-year-old gentleman who suffered an attack of pituitary apoplexy while being treated for DHF. The issues pertaining to the management of hydrocephalus, timing of surgical intervention, and treatment of electrolyte imbalances encountered in the dual setting of DHF and pituitary apoplexy are discussed with reference to the outcome in our case.

Conclusion:

Although patients suffering from DHF harbor multiple factors, which may be precipitants of pituitary apoplexy, the association between these two conditions is rare and only few case reports document their coexistence. We review the pertinent literature and discuss the management dilemmas faced by us while dealing with these dual pathological states.

Psammomatoid Juvenile Ossifying Fibroma: Report of Three Cases with a Review of Literature

Psammomatoid juvenile ossifying fibroma (PJOF), a variant of juvenile ossifying fibroma (JOF), is a locally aggressive neoplasm of the children and young adults. This entity has predilection for the sinonasal region. It forms a differential diagnosis for many bone neoplasms. We report three cases of PJOF, in young patients whose biopsy showed the presence of psammomatoid bodies in a cellular fibrous stroma. The diagnosis of JOF indicates requirement of extensive surgery due to its locally aggressive nature.

Giant Hypothalamic Hamartoma in an Infant: A Case Report and Review of the Literature

Giant hypothalamic hamartomas (GHH) are extremely rare lesions in infants and usually intrinsically epileptogenic. We present the case of a 10-month-old girl child presenting with drug-resistant seizures and a giant hypothalamic lesion that was confirmed as hamartoma on histopathology. Surgical decompression and disconnection from the hypothalamus was performed with the intent of controlling her seizures. Unfortunately, the patient developed right middle cerebral artery and posterior cerebral artery territory infarction, possibly due to vasospasm or thrombosis of the vessels. The patient had a stormy postoperative course but has recovered well neurologically at the 18-month follow-up. Histopathological examination revealed abnormal clusters of NeuN-positive neurons, which was confirmatory of hypothalamic hamartoma. A review of the published literature on infantile GHH, its management and the postoperative complications is undertaken in this short report.

Intrinsic brainstem schwannoma - A rare clinical entity and a histological enigma

Intraparenchymal schwannomas arising in the brainstem are very rare, and only eight cases have been reported in literature till now. We report an intraparenchymal brainstem schwannoma presenting with the classical clinical presentation of an intrinsic brainstem lesion, and discuss its clinicoradiological characteristics and histological origins. We highlight the importance of an intraoperative frozen section diagnosis in such cases. Intraoperative tissue diagnosis significantly may alter the surgical strategy, which should be aimed at near total intracapsular decompression of the schwannoma.

Primary parietal myeloid sarcoma

Intracranial occurrence of myeloid sarcoma without any evidence of systemic hematological disorder is uncommon. We report the case of a 17-year-old girl who presented with features of raised intracranial pressure and paraparesis of short duration. Magnetic resonance imaging showed a 6 cm bilateral middle 1/3^rd para sagittal contrast enhancing extra-axial mass with mass effect. The tumor was subtotally excised. Histology and immunohistochemistry proved to be a myelosarcoma. Further evaluation done with peripheral blood smear and bone marrow biopsy ruled out the possibility of leukemia or myeloproliferative disorder. She was referred for chemotherapy and clinically showed improvement after 6 months of follow-up. Authors report a case of intracranial myelosarcoma which closely resembled meningioma both radiologically and in intraoperative morphological appearance. Authors discuss in detail the radiological and histological features of myelosarcoma along with differential diagnoses and treatment options.

A rare posterior cranial fossa tumor

Among tumors of the central nervous system, tumors of the mixed glioneuronal type form an important recognized subset. Some of the examples for mixed glioneuronal tumors include gangliocytoma, dysembryoplastic neuroepithelial tumor (DNT), ganglioglioma, anaplastic ganglioglioma, and central neurocytoma. The rosette-forming glioneuronal tumor (RGNT) of the fourth ventricle is a new entity that has only slowly emerged in the literature due to its prior classification with other low-grade mixed glial and neuronal tumors. These tumors are relatively infrequent lesions, and therefore, they can be challenging to diagnose for the practicing pathologist. This is a rare biphasic tumor with clearly defined neurocytic and glial components. The tumor is found exclusively in the posterior fossa, where it arises in the midline, usually occupying a substantial fraction of the fourth ventricle, and it is observed by magnetic resonance imaging (MRI) as a circumscribed, solid mass with heterogeneous contrast enhancement. We describe here a case of RGNT occurring in a 22-year-old male.

Papillary thyroid carcinoma with nodular fasciitis-like stroma: a case report

Papillary thyroid carcinoma (PTC) is the most frequently occurring malignant neoplasm of the thyroid gland and is known to have several morphologic variants. PTC with nodular fasciitis-like stroma (PTC-NFS) is one of the unusual variants of PTC, with only a few cases being reported in the literature. This neoplasm is characterized by extensive reactive stromal proliferation, which may occupy 60 to 80% of the tumor along with areas of a typical papillary carcinoma. We report a case of PTC-NFS and address the diagnostic difficulties posed by the condition's extensive reactive stromal proliferation. We also emphasize that when one encounters a fibroproliferative lesion of the thyroid, a diligent search should also be made for PTC to avoid diagnostic errors.