Multifocal atypical teratoid/rhabdoid tumour in an infant-a rare case report

BACKGROUND

Atypical teratoid/rhabdoid tumours (AT/RT) are uncommon but aggressive, malignant tumours in the paediatric age group. Presentation of concomitant supratentorial and infratentorial lesions in an infant is extremely rare. We discuss an infant diagnosed with such lesions. Systematic PubMed search was conducted using keywords 'atypical teratoid /rhabdoid tumor', 'paediatric' and 'multifocal'. Reports were included for patients younger than 18 years with two or more lesions. The search yielded additional five cases and were tabulated. Age, sex, location, treatment given and survival/outcome were noted.

CASE REPORT

A 10-month-old child presented with complaints of drowsiness and intractable vomiting. Imaging showed multifocal supra- and infratentorial lesions with obstructive hydrocephalus. The child underwent ventriculoperitoneal shunt followed by surgical removal of the posterior fossa lesion. Histopathological features were consistent with AT/RT.

CONCLUSIONS

Multifocal AT/RT are very rare. The impact of multifocality in the outcome is not known as very few reports are available. Newer targeted therapies may offer insight in improving outcomes in the future.

Traumatic irreducible non-Hangman's type bilateral C2-C3 high-grade facet dislocation: technical nuance

Majority of C2-C3 vertebral dislocations occur as in combination with bilateral pars fractures, also known as Hangman's fractures. Isolated C2-C3 facet dislocation without any associated C2 fracture is a very rare injury. One such case has been presented in this report. A 29-year male was involved in a road traffic accident (RTA) after which he developed midline neck pain. Following a minor neck manipulation at a hair salon 15 days after the RTA, his neck pain worsened and he developed quadriparesis. Imaging at the time of admission showed bilateral high-grade C2-C3 facet dislocations without any associated fracture of C2 vertebra. Due to non-reduction of the dislocation with skeletal traction, surgery was contemplated. Intraoperatively, the C2-C3 joint spaces were opened but only partial reduction could be achieved. Complete reduction was achieved only after opening of the C1-C2 joints was performed. Later, C2-C4 screw-rod constructs were placed. Patient achieved good outcome with resolution of symptoms. This report concludes that, in cases of delayed presentation of irreducible C2-C3 bilateral facet dislocations and non-reducibility by skeletal traction, opening of the C1-2 joints may need to be performed in addition to the C2-C3 joint spaces, in order to achieve complete reduction.

A 2-Year Prospective Study of Complication Rates After Cranioplasty: Is 8 Weeks' Interval Associated with Increased Complications?

BACKGROUND

The commonly observed complications after cranioplasty include infections, intracranial hemorrhage, and seizures. The timing of cranioplasty after decompressive craniectomy (DC) is still under debate, with literature available for both early and delayed cranioplasties. The objectives of this study were to note the overall complication rates and more specifically compare complications between 2 different time intervals.

METHODS

This was a 24-month, single-center, prospective study. Since timing is the most debated variable, the study cohort was divided into 2 groups (≤8 weeks and >8 weeks). Furthermore, other variables such as age, gender, etiology of DC, neurologic condition, and blood loss were correlated with complications.

RESULTS

A total of 104 cases were analyzed. Two thirds were traumatic etiology. The mean and median DC-cranioplasty intervals were 11.3 weeks (range 4-52 weeks) and 9 weeks, respectively. Seven complications (6.7%) were observed in 6 patients. There was no statistical difference observed between any of the variables and complications.

CONCLUSIONS

We observed that performing cranioplasty within 8 weeks of the initial DC surgery is safe and noninferior to cranioplasty performed after 8 weeks. Therefore if the general condition of the patient is satisfactory, we are of the opinion that an interval of 6-8 weeks from the primary DC is safe and a reasonable time frame for performing cranioplasty.

Clinical outcomes and prognostic factors of traumatic basal ganglia hematomas: A 4-year single-center study

BACKGROUND

Traumatic basal ganglia hematomas (TBGH) are rare entities. They are situated in the deep cerebral parenchyma and have also been termed as intermediate coup contusions. Available literature is sparse with regards to the characteristics and prognosis of TBGH. We aim to share our experience in the management, outcomes, and prognostic factors of TBGH.

METHODS

A 4-year retrospective study which included all cases of TBGH, except dot contusions (<2 mL) and those with coagulopathies. Admission variables were correlated with Glasgow Outcome Scale score at discharge and 12 months.

RESULTS

Thirty-two patients were analyzed. The mean age was 39.2 years. Two-thirds were due to road traffic accidents. Around 60% were severe head injuries. The mean Glasgow coma scale (GCS) score at presentation was 8.5. Twenty patients had moderate-to-severe hemiparesis. The mean hematoma volume was 18.1 mL. Associated traumatic intracranial lesions were seen in 28 cases. Only 7 patients (22%) underwent surgery. The mean follow-up was 17.4 months (range 14-34 months). The mortality rate was 12.5% (n = 4). Among the survivors, only 39% (n = 11) had good outcomes at discharge which showed modest improvement to 54% (n = 15) at 12 months.

CONCLUSION

Our study noted that poor admission GCS scores, poor motor response, presence of significant hemiparesis, and larger hematoma volumes (>20 mL) correlated with poor outcomes at 12 months. The overall outcomes have been mostly unfavorable as observed in majority of studies due to deeper location of these hematomas, high proportion of severe head injuries, and high proportion of residual weakness in survivors.

Intracranial meningeal melanocytomas: Clinico-radiological characteristics and outcomes. A Literature review

OBJECTIVES

Melanocytes are neural crest derivatives. Intracranial meningeal melanocytomas (MM) are rare tumors and the available literature is sparse for these neoplasms. This present review aims to provide a detailed and comprehensive literature review of these tumors.

MATERIALS AND METHODS

By searching online databases, literature review was performed to include and analyze all cases of cranial MM reported till date. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed for the review process.

RESULTS

A total of 109 cases were analyzed. Male:female ratio was 1.2:1. The mean age was 40.3 years. The mean duration of symptoms was 23.9 months (range 2days-15 years). Cerebellopontine (CP) angle, suprasellar and Meckel cave were the most common locations. Sixty-four cases (58%) underwent GTR. Twenty-eight patients (26%) received some form of adjuvant radiation. There were 29(26%) recurrences and mean time to recurrence was 50.2 months. The recurrence rates (RR) for GTR and STR were 20% and 42% respectively. Extent of resection (STR) and tumor locations (CP angle and Meckel cave) were significantly associated with higher RR. Six (6.5%) cases had higher-grade transformations.

CONCLUSIONS

Complete surgical resection is the ideal treatment and adjuvant radiation is to be considered for residual/recurrent tumors. Adjuvant radiotherapy may also be prescribed despite GTR, in locations with higher RR such as CP angle and Meckel's cave. Because of higher-grade transformations and delayed recurrences, long-term follow-up is required.

Differential gene expression of 3D primary human airway cultures exposed to cigarette smoke and electronic nicotine delivery system (ENDS) preparations

BACKGROUND

Acute exposure to cigarette smoke alters gene expression in several biological pathways such as apoptosis, immune response, tumorigenesis and stress response, among others. However, the effects of electronic nicotine delivery systems (ENDS) on early changes in gene expression is relatively unknown. The objective of this study was to evaluate the early toxicogenomic changes using a fully-differentiated primary normal human bronchial epithelial (NHBE) culture model after an acute exposure to cigarette and ENDS preparations.

RESULTS

RNA sequencing and pathway enrichment analysis identified time and dose dependent changes in gene expression and several canonical pathways when exposed to cigarette preparations compared to vehicle control, including oxidative stress, xenobiotic metabolism, SPINK1 general cancer pathways and mucociliary clearance. No changes were observed with ENDS preparations containing up to 28 µg/mL nicotine. Full model hierarchical clustering revealed that ENDS preparations were similar to vehicle control.

CONCLUSION

This study revealed that while an acute exposure to cigarette preparations significantly and differentially regulated many genes and canonical pathways, ENDS preparations containing the same concentration of nicotine had very little effect on gene expression in fully-differentiated primary NHBE cultures.

Transcriptomic Response of Primary Human Bronchial Cells to Repeated Exposures of Cigarette and ENDS Preparations

Cigarette smoke deregulates several biological pathways by modulating gene expression in airway epithelial cells and altering the physiology of the airway epithelium. The effects of repeated exposures of electronic cigarette delivery systems (ENDS) on gene expression in airway epithelium are relatively unknown. In order to assess the effect of repeated exposures of ENDS, primary normal human bronchial epithelial (NHBE) cells grown at air-liquid interface (ALI) were exposed to cigarette and ENDS preparations daily for 10 days. Cigarette smoke preparations significantly altered gene expression in a dose-dependent manner compared to vehicle control, including genes linked to oxidative stress, xenobiotic metabolism, cancer pathways, epithelial-mesenchymal transition, fatty acid metabolism, degradation of collagen and extracellular matrix, O-glycosylation, and chemokines/cytokines, which are known pathways found to be altered in smokers. Conversely, ENDS preparations had minimal effect on transcriptional pathways. This study revealed that a sub-chronic exposure of primary NHBE cultures to cigarette and ENDS preparations differentially regulated genes and canonical pathways, with minimal effect observed with ENDS preparations compared to cigarette preparations. This study also demonstrates the versatility of primary NHBE cultures at ALI to evaluate repeat-dose exposures of tobacco products.

Sella Turcica Bridging and its Association with Dental Anomalies

Aim:

This study aimed to study the overall incidence of DA and its association with Sella Turcica bridging (STB).

Background:

Dental anomalies (DA) are associated with morphological changes in the Sella Turcica (ST).

Materials and Methods:

We retrieved the pretreatment patient records from March 2018 - March 2020 from the archives of the Orthodontics Department (n=806). We excluded the records with missing radiographs, concomitant cleft lip/ palate, history of surgical repair of cleft lip/ palate or any other craniofacial anomaly, history of trauma, and prior orthodontic treatment. A total of 676 patient records were included for initial screening, out of which 103 patients had DA (study group). A similar number of records (n=103) without any DA were randomly selected to constitute a control group. Determination of the extent of STB was done by calibrated and trained examiner. Age and sex were also recorded.

Results:

The incidence of DA was 15.24%. The most common anomalies recorded were impacted canines (6.8%) and hyperdontia (3.7%), followed by agenesis (2.1%) and others. Type III bridging in patients with DA was 22.3%, while being 9.7% in the control group. Type II bridging was observed in 36.8% of patients with DA as compared to 29.1% in the control group. The presence of partial and complete STB in patients with dental anomalies was significantly higher than in the control group (P=0.006). The study group showed significant association with STB (OR: 2.33; P=0.003; 95%CI: 1.33-4.11) after adjusting for sex.

Conclusion:

The results of our study revealed a significant association between STB and DA.

Metabolomic Analysis Identified Reduced Levels of Xenobiotics, Oxidative Stress, and Improved Vitamin Metabolism in Smokers Switched to Vuse Electronic Nicotine Delivery System

Introduction

Switching to noncombustible tobacco products presents an opportunity for cigarette smokers to potentially reduce the health risks associated with smoking. Electronic Nicotine Delivery Systems (ENDS) are one such product because the vapor produced from ENDS contains far fewer toxicants than cigarette smoke. To investigate the biochemical effects of switching from smoking to an ENDS, we assessed global metabolomic profiles of smokers in a 7-day confinement clinical study.

Methods

In the first 2 days of this clinical study, the subjects used their usual brand of cigarettes and then switched to exclusive ENDS ad libitum use for 5 days. Urine and plasma samples were collected at baseline and 5 days after switching. The samples were analyzed using a mass spectrometry-based metabolomic platform.

Results

Random forest analyses of urine and plasma metabolomic data revealed excellent predictive accuracy (>97%) of a 30-metabolite signature that can differentiate smokers from 5-day ENDS switchers. In these signatures, most biomarkers are nicotine-derived metabolites or xenobiotics. They were significantly reduced in urine and plasma, suggesting a decreased xenobiotic load on subjects. Our results also show significantly decreased levels of plasma glutathione metabolites after switching, which suggests reduced levels of oxidative stress. In addition, increased urinary and plasma levels of vitamins and antioxidants were identified, suggesting enhanced bioavailability due to discontinuation of cigarette smoking and switching to Vuse ENDS use.

Conclusions

Our results suggest reduced toxicant exposure, reduced oxidative stress, and potential beneficial changes in vitamin metabolism within 5 days in smokers switching to Vuse ENDS.

Implications

Switching from smoking to exclusive ENDS use in clinical confinement settings results in significant reduction of nicotine metabolites and other cigarette-related xenobiotics in urine and plasma of subjects. Significantly decreased oxidative stress-related metabolites and increased urinary and plasma levels of vitamin metabolites and antioxidants in 5-day short-term ENDS switchers suggest less toxic physiological environment for consumers of ENDS products and potential health benefits if such changes persist.

Steroids for delayed cerebral edema after traumatic brain injury

Background

Brain edema is a common phenomenon after traumatic brain injury (TBI) resulting in increased intracranial pressure and subsequent neurological deterioration. Experimental studies have proven that brain edema is biphasic (cytotoxic followed by vasogenic). Till date, all studies, including the corticosteroid randomization after significant head injury (HI) trial, have used high-dose steroids in the acute period during which the edema is essentially cytotoxic in nature. No clinical data exist pertaining to delayed cerebral edema (vasogenic) and steroids.

Methods

Patients who had received steroids for delayed cerebral edema after TBI were retrospectively analyzed over a 2-year period. Steroid dose, timing of steroid prescription, time to improvement of symptoms, and complications were noted.

Results

There were six males and three females. Mean age was 41.1 years. There were no severe HI cases. All subjects had cerebral contusions on imaging. Dexamethasone was the preferred steroid starting with 12 mg/day and tapered in 5-7 days. The mean interval to steroid administration after trauma was 7 days. The mean duration of steroid prescription was 6.3 days. All patients had complete symptomatic improvement. The mean time to symptom resolution was 3.8 days. No patients experienced any complications pertinent to steroid usage.

Conclusion

This is the first study to document efficacy of steroids for delayed cerebral edema after TBI, at least in mild/moderate head injuries. The timing of steroid usage and dose of steroids is key aspects that might determine its efficacy in TBI which was the drawbacks of the previous studies. Future prospective trials with the above factors in consideration may confirm/refute above findings.

Cigarette smoke preparations, not electronic nicotine delivery system preparations, induce features of lung disease in a 3D lung repeat-dose model

Cigarette smoking is a risk factor for several lung diseases, including chronic obstructive pulmonary disease, cardiovascular disease, and lung cancer. The potential health effects of chronic use of electronic nicotine delivery systems (ENDS) is unclear. This study utilized fully differentiated primary normal human bronchial epithelial (NHBE) cultures in a repeat-dose exposure to evaluate and compare the effect of combustible cigarette and ENDS preparations. We show that 1-h daily exposure of NHBE cultures over a 10-day period to combustible cigarette whole smoke-conditioned media (WS-CM) increased expression of oxidative stress markers, cell proliferation, airway remodeling, and cellular transformation markers and decreased mucociliary function including ion channel function and airway surface liquid. Conversely, aerosol conditioned media (ACM) from ENDS with similar nicotine concentration (equivalent-nicotine units) as WS-CM and nicotine alone had no effect on those parameters. In conclusion, primary NHBE cultures in a repeat-dose exposure system represent a good model to assess the features of lung disease. This study also reveals that cigarette and ENDS preparations differentially elicit several key endpoints, some of which are potential biomarkers for lung cancer or chronic obstructive pulmonary disease (COPD).

Intraoperative Temporal Horn Ventriculostomy for Brain Relaxation During Aneurysm Surgeries in Pterional Approaches

BACKGROUND

Achieving optimal brain relaxation is paramount in aneurysm surgery. Despite proper positioning and the use of newer anesthetic drugs and the administration of decongestants, it is often not possible to achieve satisfactory relaxation, which can lead to neurological deficits owing to excessive brain retraction. The present study aimed to provide detailed surgical notes regarding the novel technique of temporal horn tapping for intraoperative ventriculostomy.

METHODS

The hospital records of anterior circulation aneurysm surgery performed during the previous 5 years were retrieved. Only those cases in which we had used temporal horn tapping were included. Ventriculostomy was performed only in those cases in which the brain was tense despite the administration of decongestants. A small corticectomy was performed over the middle temporal gyrus and deepened to access the temporal horn.

RESULTS

This technique was used in 84 surgical cases. The mean patient age was 52.8 years. The male/female ratio was 1:1.4. Anterior communicating artery aneurysms were the most common. Adequate brain relaxation was satisfactorily achieved in all cases. Two patients had developed a small temporal hematoma attributable to the temporal corticectomy, both managed conservatively.

CONCLUSIONS

We believe that this new trajectory through the middle temporal gyrus to access the temporal horn is very safe because of the lack of proximity to any blood vessel or critical structures. We recommend the use of this technique during pterional approaches for acute aneurysmal surgery in the tight, bulging brain to achieve relaxation and avoid secondary complications such as retraction contusions and resultant cerebral edema.

Decompressive Craniectomy in Spontaneous Intracerebral Hemorrhage: A Comparison with Standard Craniotomy Using Propensity-Matched Analysis

BACKGROUND

Spontaneous intracerebral hemorrhage carries a poor prognosis with a 30-day mortality rate of 35%-52%. There is no standardized surgical technique for treatment of spontaneous intracerebral hemorrhage. While minimally invasive techniques are popular, there has been renewed interest in decompressive craniectomy (DC). We compared surgical and functional outcomes of standard craniotomy and DC, both with hematoma evacuation, in the surgical treatment of supratentorial spontaneous intracerebral hemorrhage.

METHODS

This 4-year retrospective study compared outcomes of 2 surgical techniques: standard craniotomy in group A (n = 78) and DC in group B (n = 54). To minimize bias in case selection, propensity matching was performed to match preoperative Glasgow Coma Scale score and hematoma volume (group C).

RESULTS

Hematoma evacuation was performed in 132 patients. Mean age of patients was 53.3 years, 50.5 years, and 52.06 years in groups A, B, and C, respectively. Median preoperative Glasgow Coma Scale score was 9, 7, and 8 (P = 0.01; P = 0.45), and mean hematoma volume was 46.21 mL, 50.91 mL, and 49.90 mL. Overall mortality was 26.5%; 62.9% (n = 22) of deaths were in group A, and 37.1% (n = 13) were in group B (P = 0.69). Median modified Rankin Scale score was similar in both groups, both at discharge and at 3 months. After determining propensity scores, mortality and outcomes of matched groups remained similar.

CONCLUSIONS

DC with hematoma evacuation does not appear to provide a significant advantage over standard craniotomy with regard to functional outcomes and mortality. DC may overcome the need for subsequent surgery in accommodating postoperative mass effect in residual bleeds and rebleeds but is associated with greater blood loss and longer operative duration.

Outcomes of Cranioplasty from a Tertiary Hospital in a Developing Country

Introduction

Although cranioplasty (CP) is a straightforward procedure, it may result in a significant number of complications. These include infections, seizures, intracranial hematomas, and others. Many reports have stated that early CP is associated with higher complications; however, more recent articles have contradicted this opinion. We intend to share our experience and results on outcomes of CP from our university hospital.

Materials and Methods

This is a 3-year retrospective analysis of patients undergoing CP. Demographic profile, etiology of decompressive craniectomy (DC), DC-CP interval, operative details, complications, and follow-up data were analyzed. Correlation of complications with timing of CP and other factors was studied to look for statistical significance.

Results

A.

total of 93 cases were analyzed. The majority were traumatic and ischemic stroke etiologies. There were eight open/compound head injuries (HIs). Eleven were bilateral and the rest unilateral cases. The mean and median CP interval were 8.5 weeks (range 4-28 weeks) and 8 weeks, respectively. All patients received 48 h to up to 5 days of postoperative antibiotics. Ten complications (10.7%) were noted (including one death). Poor Glasgow Outcome Scale at CP was the only statistically significant factor associated with higher complication rates. There was no statistical difference with respect to gender, CP material, and etiology; however, early CP had slightly fewer complications.

Conclusion

Patients with poor neurological condition at the time of CP have a significantly higher risk of complications. Contrary to earlier reports, early CP (<12 weeks) was not associated with higher complications but rather fewer complications than delayed procedures. Adherence to a few simple steps may help reduce these complications.

Combustible Cigarette and Smokeless Tobacco Product Preparations Differentially Regulate Intracellular Calcium Mobilization in HL60 Cells

Changes in the level of intracellular calcium ([Ca²⁺]_i) are central to leukocyte signaling and immune response. Although evidence suggests that cigarette smoking affects inflammatory response via an increase in intracellular calcium, it remains unclear if the use of smokeless tobacco (e.g., moist snuff) elicits a similar response. In this study, we evaluated the effects of tobacco product preparations (TPPs), including total particulate matter (TPM) from 3R4F reference cigarettes, smokeless tobacco extract (STE) from 2S3 reference moist snuff, and nicotine alone on Ca²⁺ mobilization in HL60 cells. Treatment with TPM, but not STE or nicotine alone, significantly increased [Ca²⁺]_i in a concentration-dependent manner in HL60 cells. Moreover, TPM-induced [Ca²⁺]_i increase was not related to extracellular Ca²⁺ and did not require the activation of the IP3 pathway nor involved the transient receptor potential (TRP) channels. Our findings indicate that, in cells having either intact or depleted endoplasmic reticulum (ER) Ca²⁺ stores, TPM-mediated [Ca²⁺]_i increase involves cytosolic Ca²⁺ pools other than thapsigargin-sensitive ER Ca²⁺ stores. These results, for the first time, demonstrate that TPM triggers [Ca²⁺]_i increases, while significantly higher nicotine equivalent doses of STE or nicotine alone, did not affect [Ca²⁺]_i under the experimental conditions. In summary, our study suggests that in contrast with STE or nicotine preparations, TPM activates Ca²⁺ signaling pathways in HL60 cells. The differential effect of combustible and non-combustible TPPs on Ca²⁺ mobilization could be a useful in vitro endpoint for tobacco product evaluation.

Clinical Profile and Predictors of Outcome in Spontaneous Intracerebral Hemorrhage from a Tertiary Care Centre in South India

Background. This article attempts to evaluate the clinical profile and outcome determinants following hypertensive SICH in a South Indian population. The study represents the largest series of SICH reported from a single centre in India. Materials and Methods. Prospective data collection and analysis of patients with SICH admitted to our centre between 1st January 2015 and 31st December 2018. The variables analysed include: age, sex, comorbidities, Glasgow coma score (GCS) on admission, radiological features, treatment modality, and outcome at three months. Modified Rankin score (mRS) was used to assess the outcome at discharge and three months. Results. Our study group of 905 patients included 638 males and 267 females and the mean age at presentation was 58.10 ± 12.76 years. The study group included 523 patients (57.8%) previously diagnosed hypertensive, of whom 36.3% (n = 190) were on irregular medication. The most frequent locations of hematoma were basal ganglia (478), thalamus (202), lobar (106), cerebellar (61), brainstem (31), and primary intraventricular haemorrhage (27). Secondary intraventricular extension was seen in 425 (47%) patients on admission. The mean volume of the clot on admission was 23.45 ± 19.79 ml, and clot progression was seen in only 46 (5.08%) cases. Surgical evacuation through craniotomy was done in 147 (16.8%) patients, and external ventricular drainage (EVD) was placed in 56 (6.2%) patients. Overall 3-month mortality was 30.1% (266 patients). On the last follow up a favorable outcome (mRS 0-3) was observed in 412 (45.53%) patients and a poor outcome (mRS 4-5) in 207 patients (22.87%). Independent predictors of mortality are Age >70 (p = <0.001, OR 4.806, 95% CI 3.064-7.54), admission GCS <8 (p = <0.001, OR7.684, 95% CI 5.055#x2013;11.68), and Hematoma volume >30 ml (p = <0.001, OR 2.45, 95% CI 1.626-3.691). Intraventricular haemorrhage was an additional poor outcome predictor (p < 0.015, CI 1.105-2.585). Surgical evacuation reduced mortality in the group, but morbidity rates remained the same. Conclusions. SICH predominantly affects a younger population in India in comparison to the Western society. Elderly age, poor GCS on admission, clot volume above 30 ml and intraventricular extension remain the most consistent predictors of death and poor outcome. Further studies are needed to assess the risk of SICH among hypertensive patients and to prognosticate the outcome after SICH using novel predictors, including biomarkers.

Cranial Melioidosis Presenting as Osteomyelitis and/or Extra-Axial Abscess: Literature Review

BACKGROUND

Central nervous system (CNS) melioidosis is rare. Clinical presentations depend on the region of endemicity. Despite treatment, neurologic disease has relatively high mortality rates. Less than 80 cases of CNS involvement have been reported.

METHODS

A literature review was performed by searching online databases for melioidosis presenting as osteomyelitis or scalp/extra-axial abscess (OSEAA). In addition, 3 similar cases managed at my institute have been presented.

RESULTS

Including this report of 3 cases, 20 additional cases have been reported. Of these, 12 cases (60%) were from India. The mean age of patients was 45.5 years (range, 29-74 years), and none were in the pediatric age group. Patients in the fifth to sixth decades were most frequently affected. The male to female ratio was 5.3:1. Eleven patients had predisposing factors. Fever, headache, and scalp swelling were the most common features. Five cases had history of previous melioid infection. Seven cases had systemic disease. Debridement was performed in 11 cases. The average intensive phase treatment duration was 4.6 weeks (range, 2-8 weeks) and 5.5 months (range, 3-12 months) for the maintenance phase. Mean follow-up duration was 13.5 months (range, 2 weeks-40 months). Two deaths (10%) were reported, and 1 case of residual frontal abscess had relapse.

CONCLUSIONS

Cranial melioidosis presenting as OSEAA is associated with good outcome, in contrast with other neurologic presentations. Intensive phase for at least 2-3 weeks followed by maintenance phase for 3-6 months is the standard treatment, similar to other melioid presentations. A high degree of suspicion and accurate identification of the organism is crucial. Patients need to be monitored for recurrences, both clinically and radiologically.

Pathway Analysis of Global Metabolomic Profiles Identified Enrichment of Caffeine, Energy, and Arginine Metabolism in Smokers but Not Moist Snuff Consumers

Existing US epidemiological data demonstrate that consumption of smokeless tobacco, particularly moist snuff, is less harmful than cigarette smoking. However, the molecular and biochemical changes due to moist snuff consumption relative to smoking remain incompletely understood. We previously reported that smokers (SMK) exhibit elevated oxidative stress and inflammation relative to moist snuff consumers (MSC) and non-tobacco consumers (NTC), based on metabolomic profiling data of saliva, plasma, and urine from MSC, SMK, and NTC. In this study, we investigated the effects of tobacco consumption on additional metabolic pathways using pathway-based analysis tools. To this end, metabolic pathway enrichment analysis and topology analysis were performed through pair-wise comparisons of global metabolomic profiles of SMK, MSC, and NTC. The analyses identified >8 significantly perturbed metabolic pathways in SMK compared with NTC and MSC in all 3 matrices. Among these differentially enriched pathways, perturbations of caffeine metabolism, energy metabolism, and arginine metabolism were mostly observed. In comparison, fewer enriched metabolic pathways were identified in MSC compared with NTC (5 in plasma, none in urine and saliva). This is consistent with our transcriptomics profiling results that show no significant differences in peripheral blood mononuclear cell gene expression between MSC and NTC. These findings, taken together with our previous biochemical, metabolomic, and transcriptomic analysis results, provide a better understanding of the relative changes in healthy tobacco consumers, and demonstrate that chronic cigarette smoking, relative to the use of smokeless tobacco, results in more pronounced biological changes, which could culminate in smoking-related diseases.

Delayed Facial Palsy after Microvascular Decompression: Report of Two Cases

Microvascular decompression (MVD) is a novel surgical procedure predominantly performed for treating trigeminal neuralgia (TN) and hemifacial spasm (HS). Multiple studies have proven the long-term success of MVD for both these conditions. The most common complications of MVD reported include chemical meningitis, facial hypesthesia, cerebrospinal fluid leak, facial paresis, and hearing loss. Delayed facial palsy (DFP) is an uncommon complication mostly noted in MVD for HS and after the removal of acoustic tumors. We report two cases of DFP occurring after performing MVD, one each for HS and TN. This is also the first case of DFP to be reported after MVD for TN. Both were young females who developed DFP 2 weeks after surgery. They were managed with oral steroids and acyclovir for 2–3 weeks and achieved excellent outcome at an average of 4.5 weeks from the onset. We conclude that although majority of the cases improve spontaneously, steroids and acyclovir might assist in faster recovery.

Global gene expression profiles from PBMCs treated with reference tobacco product preparations

This Data in Brief article describes global gene expression profiles from human peripheral blood mononuclear cells (PBMCs) that were treated with preparations from reference combustible and non-combustible tobacco products (TPPs). PBMCs isolated from non-smokers were treated with three non-cytotoxic doses of aqueous preparations from 3R4F cigarettes, termed Whole Smoke-Conditioned Medium (WS-CM) and a single dose of 2S3 moist snuff, termed smokeless tobacco extract (STE). PBMCs were treated with the test articles for 3 hours and the extracted total RNA was reverse transcribed and hybridized to HTA 2.0 Genechip^® arrays and scanned using an Affymetrix GeneChip^® Scanner 3000. CEL files and CHP files were generated using an Affymetrix Expression console. The CEL files were submitted to the NCBI database with GEO accession number GSE110027. The results of the microarray analyses are found in this Data in Brief article. Ingenuity Pathway Analysis (IPA; Qiagen) was used to conduct core analyses of genes that were differentially expressed by high WS-CM or STE based on the Ingenuity Gene knowledge. Expression of several of the differentially expressed genes was confirmed by RT-PCR. Analyses of these data can be found in the article “Distinct gene expression changes in human peripheral blood mononuclear cells treated with different tobacco product preparations” [1].

Spontaneous orbital haemorrhage secondary to cavernous haemangioma - a case summary and review of literature

PURPOSE

Orbital haemangiomas are common orbital tumors known for their slow growth. Acute presentation with haemorrhage into the tumor is a rare occurrence with only nine cases reported in literature.

METHODS

The authors present a case of an elderly female with sudden onset of proptosis and swelling of the eye. There was a transient relief of symptoms with steroids with residual proptosis and ptosis at two weeks. Magnetic resonance imaging revealed an intraconal soft tissue mass in the inferolateral quadrant of the left orbit with a differential diagnosis of haemangioma with bleed or metastasis.

RESULTS

Patient underwent a lateral orbitotomy and tumour excision and histopathological examination revealed a cavernous haemangioma with a thrombus. The patient had complete symptomatic recovery following surgery.

CONCLUSION

Orbital haemangiomas presenting with haemorrhage is rare and should be differentiated from orbital venous anomalies prior to surgery.

A comprehensive review of adult onset spinal teratomas: analysis of factors related to outcomes and recurrences

PURPOSE

Spinal teratomas are rare tumours noted in adults and are commonly located in the thoracolumbar region. Currently, there appears to be a lack of clear consensus regarding the management and prognosis of these lesions. A comprehensive review along with an illustrative case managed at the author's institute has been presented.

MATERIALS AND METHODS

Online database search was performed for literature review.

RESULTS

A 26-year-old male presented with acute onset neurological deficits and imaging revealed features of conus teratoma. Subtotal resection was performed and patient achieved fair recovery. Including the present one, a total of 146 cases have been reported and were analysed. Mean age was 39.6 years (range 18-85 years) and males predominated. Limb weakness and backache were the commonest symptoms. Majority of the lesions were intramedullary and located in the thoracolumbar region. Complete resection (CR) was achieved in 45% of cases. All, except one, were mature teratomas. Recurrences were noted in nine (6.1%) cases. Outcome was good/excellent in 86 (60%) and fair/poor in 26 (18%) cases. The presence of pain, absence of limb weakness and CR were significantly associated with good outcomes. Furthermore, subtotal resection (STR) had significantly higher recurrence rates than CR. Four deaths (2.7%) were noted.

CONCLUSIONS

Total surgical resection is the standard treatment and appears to be beneficial both in terms of outcomes and recurrences. Overall, recurrences are rare and may be managed by re-surgery. In addition, the present report is the eighth case of adult spinal teratoma with an acute onset presentation. These slides can be retrieved under Electronic Supplementary Material.

Spinal Intramedullary Abscess Secondary to Dermal Sinus in Children

INTRODUCTION

 Congenital dermal sinuses (CDS) are uncommon lesions. They are most often noted in lumbosacral region and may lead to meningitis or spinal abscess. Intramedullary spinal cord abscess (IMSCA) due to CDS is rare and often co-exists with an inclusion tumor such as dermoid/epidermoid cyst.

MATERIALS AND METHODS

 Literature review was done to analyze all cases of pediatric IMSCA secondary to CDS by searching online databases starting from the oldest case reported.

RESULTS

 Only 50 cases have been reported and were analyzed. Mean age was 22.6 months (range 1 month-15 years). Fever, acute flaccid lower limb weakness, and urinary disturbances were the most common presenting features. Dermal sinus was commonest in lumbosacral region. Inclusion cysts were observed in 50% of cases. Staphylococcus aureus was the most the common organism. Mean follow-up duration was 18.2 months (range 1 week-156 months). Majority of the cases underwent multilevel laminectomy with myelotomy and drainage of abscess. Outcome was good-to-excellent in around 60% cases with four deaths. Presence of fever and limb weakness was significantly associated with poor outcomes.

CONCLUSION

 Intramedullary abscess secondary to CDS is very rare. Complete sinus tract excision, myelotomy and drainage of abscess, and decompression of co-existent inclusion cysts with prolonged antibiotic therapy remain the standard treatment. Approximately 60% cases achieve good outcomes. Fever and limb weakness portend poorer outcomes than those without.

Distinct gene expression changes in human peripheral blood mononuclear cells treated with different tobacco product preparations

Cigarette smoking exerts diverse physiological effects including immune suppression. To better characterize the biological effects of different categories of tobacco products, a genome-wide gene expression study was performed. Transcriptomic profiling was performed in PBMCs treated with different equi-nicotine units of aqueous extracts of cigarette smoke (termed Whole Smoke-Conditioned Medium, or WS-CM), or a single dose smokeless tobacco extract (STE) prepared from reference tobacco products. WS-CM induced dose-dependent changes in the expression of several genes. No significant expression differences between low WS-CM and media control were detected. However, transcripts were significantly affected by medium WS-CM (479), high WS-CM (2, 703), and STE (2, 156). The overlap between medium WS-CM and STE, and high WS-CM and STE, was minimal (34 and 65 transcripts, respectively). Hierarchical clustering revealed that gene expression profiles for STE and medium WS-CM co-clustered, while those affected by the high dose of WS-CM clustered distinctly. Functional analysis revealed that WS-CM, but not STE, uniquely affected genes involved in immune cell development and inflammatory response. Cascades of upstream regulators (e.g., TNF, IL1β, NFƙB) were identified for the observed gene expression changes and generally suppressed by WS-CM, but not by STE. Collectively, these findings demonstrate that combustible and non-combustible tobacco products elicit distinct biological effects, which could explain the observed chronic immune suppression in smokers.

An All-Anterior Approach for Quadruple Nerve Transfer for Upper Trunk Brachial Plexus Injuries

BACKGROUND

The most commonly performed nerve transfers in upper trunk (UT) or partial brachial plexus injuries (BPIs) include the spinal accessory nerve to suprascapular nerve, Oberlin, and, lately, radial nerve (RN) (branch to triceps) to axillary nerve (AN) transfers. Routinely, the former 3 procedures are performed through an anterior approach (supraclavicular plus infraclavicular), while the triceps branch of the RN-AN transfer has been performed through a posterior approach with the patient in either the prone or semilateral position, which requires a separate incision in the posterior arm. The aim of the present study was to report the outcomes for 4 cases of quadruple nerve transfers performed for UT BPI using an all-anterior approach.

METHODS

The functional outcomes of 4 consecutive cases of UT BPI treated using an all-anterior approach were analyzed in terms of improvement in motor power and range of motion at the shoulder and elbow joints.

RESULTS

The mean age was 27.5 years (range, 16-40). All had sustained injuries from road traffic accidents. The mean injury to surgery interval was 4.5 months (range, 3-6). Of the 4 patients, 2 each had pre- and postganglionic injuries. All 4 patients had 0 of M0 power in shoulder abduction and external rotation, and elbow flexion. At a mean follow-up of 28.6 months, the average shoulder abduction was 157°, with an average of 82° of external rotation. The mean elbow flexion was 104°.

CONCLUSIONS

This technique appears to be feasible, with good-to-excellent outcomes achieved without requiring a separate posterior arm incision for the RN-AN transfer.

Role of Oxidative Stress in the Suppression of Immune Responses in Peripheral Blood Mononuclear Cells Exposed to Combustible Tobacco Product Preparation

Cigarette smoking is a major risk factor for several human diseases. Chronic inflammation, resulting from increased oxidative stress, has been suggested as a mechanism that contributes to the increased susceptibility of smokers to cancer and microbial infections. We have previously shown that whole-smoke conditioned medium (WS-CM) and total particulate matter (TPM) prepared from Kentucky 3R4F reference cigarettes [collectively called as combustible tobacco product preparations (TPPs)] potently suppressed agonist-stimulated cytokine secretion and target cell killing in peripheral blood mononuclear cells (PBMCs). Here we have investigated the role of oxidative stress from TPPs, which alters inflammatory responses in vitro. Particularly, we investigated the mechanisms of WS-CM-induced suppression of select cytokine secretions in Toll-like receptor (TLR) agonist-stimulated cells and target cell killing by effector cells in PBMCs. Pretreatment with N-acetyl cysteine (NAC), a precursor of reduced glutathione and an established anti-oxidant, protected against DNA damage and cytotoxicity caused by exposure to WS-CM. Similarly, secretion of tumor necrosis factor (TNF), interleukin (IL)-6, and IL-8 in response to TLR-4 stimulation was restored by pretreatment with NAC. Target cell killing, a functional measure of cytolytic cells in PBMCs, is suppressed by WS-CM. Pretreatment with NAC restored the target cell killing in WS-CM treated PBMCs. This was accompanied by higher perforin levels in the effector cell populations. Collectively, these data suggest that reducing oxidative stress caused by cigarette smoke components restores select immune responses in this ex vivo model.

Neurosurgery at Kasturba Medical College: Past, present and future

Kasturba Medical College (KMC), Manipal, is the oldest and one of the most reputed medical institutes in coastal Karnataka, catering to a population of over 4 million, spanning a stretch of over 350 kms along the southwest coast of India from Mangalore to Goa. The Department of Neurosurgery at KMC, established in 1968, continues to be the leading and most preferred referral center providing high quality neurosurgical services in this region. The article provides an insight into the origin of the department, its infancy and teething troubles, its continuous growth and landmark achievements over the years. This brief review also highlights the current area of focus and describes the plans for its future development.

AKR1C1 as a Biomarker for Differentiating the Biological Effects of Combustible from Non-Combustible Tobacco Products

Smoking has been established as a major risk factor for developing oral squamous cell carcinoma (OSCC), but less attention has been paid to the effects of smokeless tobacco products. Our objective is to identify potential biomarkers to distinguish the biological effects of combustible tobacco products from those of non-combustible ones using oral cell lines. Normal human gingival epithelial cells (HGEC), non-metastatic (101A) and metastatic (101B) OSCC cell lines were exposed to different tobacco product preparations (TPPs) including cigarette smoke total particulate matter (TPM), whole-smoke conditioned media (WS-CM), smokeless tobacco extract in complete artificial saliva (STE), or nicotine (NIC) alone. We performed microarray-based gene expression profiling and found 3456 probe sets from 101A, 1432 probe sets from 101B, and 2717 probe sets from HGEC to be differentially expressed. Gene Set Enrichment Analysis (GSEA) revealed xenobiotic metabolism and steroid biosynthesis were the top two pathways that were upregulated by combustible but not by non-combustible TPPs. Notably, aldo-keto reductase genes, AKR1C1 and AKR1C2, were the core genes in the top enriched pathways and were statistically upregulated more than eight-fold by combustible TPPs. Quantitative real time polymerase chain reaction (qRT-PCR) results statistically support AKR1C1 as a potential biomarker for differentiating the biological effects of combustible from non-combustible tobacco products.

Primary Orbital Follicular Lymphoma: A Case Report and Review

Orbital Lymphomas (OL) constitute a heterogeneous group of lymphoproliferative disorders of the orbit. They are predominantly of the Mucosa-Associated Lymphoid Tissue (MALT) subtype. Radiotherapy is the mainstay of treatment in localized orbital tumours, while chemotherapy is reserved for systemic disease. Authors report a case of a primary orbital lymphoma of follicular subtype (stage 1E) in a 54-year-old female managed by surgery and adjuvant radiotherapy.

Gene expression profiles associated with cigarette smoking and moist snuff consumption

Background

Among the different tobacco products that are available on the US market, cigarette smoking is shown to be the most harmful and the effects of cigarette smoking have been well studied. US epidemiological studies indicate that non-combustible tobacco products are less harmful than smoking and yet very limited biological and mechanistic information is available on the effects of these alternative tobacco products. For the first time, we characterized gene expression profiling in PBMCs from moist snuff consumers (MSC), compared with that from consumers of cigarettes (SMK) and non-tobacco consumers (NTC).

Results

Microarray analysis identified 100 differentially expressed genes (DEGs) between the SMK and NTC groups and 46 DEGs between SMK and MSC groups. However, we found no significant differences in gene expression between MSC and NTC. Both hierarchical clustering and principle component analysis revealed that MSC and NTC expression profiles were more similar than to SMK. Random forest classification identified a subset of DEGs which predicted SMK from either NTC or MSC with high accuracy (AUC 0.98).

Conclusions

PMBC gene expression profiles of NTC and MSC are similar to each other, while SMK exhibit distinct profiles with alterations in immune related pathways. In addition to discovering several biomarkers, these studies support further understanding of the biological effects of different tobacco products.

Trial registration

ClinicalTrials.gov. Identifier: NCT01923402. Date of Registration: August 14, 2013. Study was retrospectively registered.

Electronic supplementary material

The online version of this article (doi:10.1186/s12864-017-3565-1) contains supplementary material, which is available to authorized users.