Consensus-Based Development of a Global Registry for Traumatic Brain Injury: Establishment, Protocol, and Implementation

BACKGROUND AND OBJECTIVES

Global disparity exists in the demographics, pathology, management, and outcomes of surgically treated traumatic brain injury (TBI). However, the factors underlying these differences, including intervention effectiveness, remain unclear. Establishing a more accurate global picture of the burden of TBI represents a challenging task requiring systematic and ongoing data collection of patients with TBI across all management modalities. The objective of this study was to establish a global registry that would enable local service benchmarking against a global standard, identification of unmet need in TBI management, and its evidence-based prioritization in policymaking.

METHODS

The registry was developed in an iterative consensus-based manner by a panel of neurotrauma professionals. Proposed registry objectives, structure, and data points were established in 2 international multidisciplinary neurotrauma meetings, after which a survey consisting of the same data points was circulated within the global neurotrauma community. The survey results were disseminated in a final meeting to reach a consensus on the most pertinent registry variables.

RESULTS

A total of 156 professionals from 53 countries, including both high-income countries and low- and middle-income countries, responded to the survey. The final consensus-based registry includes patients with TBI who required neurosurgical admission, a neurosurgical procedure, or a critical care admission. The data set comprised clinically pertinent information on demographics, injury characteristics, imaging, treatments, and short-term outcomes. Based on the consensus, the Global Epidemiology and Outcomes following Traumatic Brain Injury (GEO-TBI) registry was established.

CONCLUSION

The GEO-TBI registry will enable high-quality data collection, clinical auditing, and research activity, and it is supported by the World Federation of Neurosurgical Societies and the National Institute of Health Research Global Health Program. The GEO-TBI registry ( https://geotbi.org ) is now open for participant site recruitment. Any center involved in TBI management is welcome to join the collaboration to access the registry.

Chaotic lipoma with proximal syrinx -a (not so) rare variant - review of the literature, possible embryology and management

Chaotic lipomas are an extremely rare variant of spinal lipomas. This entity was first defined in 2009 by Pang and colleagues. Not much has been written about this variant. Its characteristic is the haphazard distribution of DREZ (Dorsal root entry zone), nerve roots and placode-lipoma interface. Thus complete/near-total excision of this lesion is quite difficult. We describe a case of chaotic spinal lipoma and elucidate the challenges faced in the management of this entity and review the literature. We performed a thorough systematic review with the keyword 'chaotic', 'Lipomyelomeningocele', 'Complex Lipomyelomeningocele', 'LMMC', 'Lumbar lipoma', 'spinal lipoma' in the google scholar and PUBMED data system for indexed literature on the above topic with no particular time frame. The studies quoted range earliest from 1970 till currently. Additional potential relevant articles were further retrieved through a manual search of references from original reports. Out of 42 studies, a total of 21 publications were selected which could have encountered a chaotic variant, but due to the term introduced only recently in 2009, may have been described differently. Studies encompassing true lipomeningomyelocele were excluded from our review. What we found out? Chaotic lipoma may not be a new entity. The scarce description in literature may be in part due to non-introduction and unclear description of this term earlier. The management of this variant is particularly challenging with basic principles remaining the same. Meticulous near-total excision and placode-lipoma construct are the major obstacles.

Intracranial high-grade glioma with malignant progression of spinal intramedullary metastasis: an atypical presentation with review of literature

PURPOSE

High-grade gliomas (grade 3 and grade 4) are known to be highly locally invasive and distant metastasis though known, rarely manifest clinically due to poor survival. Recently, due to increasing survival in view of early diagnosis at relatively young age, more cases of extra neural symptomatic metastasis are being diagnosed and treated. Among these, symptomatic spinal metastasis is even more rare. Dissemination of GBM to the spinal compartment, albeit uncommon, has an even poorer outcome, with most patients dying within 2-3 months after diagnosis of metastatic disease.

MATERIALS AND METHODS

Here, we present a rare case report of a 25-year-old female with transformed/histologically progressed tumour in cranial region along with ultra-rapid progression of the spinal disease following metastasis. Proper consent of the patient relatives was taken prior to production of material as patient had expired by the time of writing of this paper. We also present an extensive review of spinal metastasis secondary to intracranial high-grade gliomas starting from 1950. We conducted a thorough and exhaustive systematic search and review of the indexed databases available in PUBMED, COCHRANE and GOOGLE SCHOLAR with key words 'spinal metastasis of glioma', 'spinal metastasis', 'glioma progression', 'secondary glioma', multicentric glioma', 'secondary spinal metastasis' and formulated a comprehensive table of the studies that met the set standards. The studies that included (a) Number of cases, (b) Age and sex of patients, (c) operated primary or non-operated primary with spinal metastasis, (d) time period from the index cranial surgery, (e) outcome after diagnosis of spine metastasis and (f) histopathology of both cranial and spinal tumour either following surgery or autopsy have been elucidated herewith. We searched the databases with no particular time period. Out of 42 case reports and series, 28 studies were selected for our publication as they met the standards set, starting from 1950 to 2020.

RESULTS

In this case, the primary histopathological diagnosis post cranial tumour removal was Grade-3 anaplastic astrocytoma, whereas Spinal autopsy report done 16 months after the primary diagnosis showed Grade-4 GBM suggestive of secondary transformation (Secondary GBM), it showed same genome of IDH mutation and ATRX loss, neoplastic fibrillary and gemistocytic astrocytes with de-differentiation, foamy histiocytes as seen in primary lesion suggestive of progression and metachronicity rather than multicentricity or synchronicity. What is more peculiar and rare in our case is that the spinal disease was very malignant and it progressed in course of just two days to involve the whole spine.

Validity of Glasgow outcome scale-extended (GOSE) mobile application for assessment of outcome in traumatic brain injury patients

PURPOSE

To develop the Glasgow Outcome Scale-Extended (GOSE) mobile application and examine the validity of the application against GOSE scoring based on traditional interview method.

METHODS

Concurrent validity was determined by comparing two independent raters' scoring for GOSE of 102 patients with traumatic brain injury, who had attended outpatient department of a tertiary neuro hospital. Agreement was assessed between the traditional interview-based pen and paper scoring and algorithm based mobile application scoring of GOSE.

RESULTS

Agreement was tested using Cohen's kappa, and the analysis revealed near perfect agreement between two raters (0.89) (p < 0.01).

CONCLUSION

The GOSE mobile application can measure GOSE Score similar to the traditional interview method. This application may help fasten the process of assessing outcome in TBI patients in clinical practice and in research.

An international, prospective observational study on traumatic brain injury epidemiology study protocol: GEO-TBI: Incidence

Background

The epidemiology of traumatic brain injury (TBI) is unclear - it is estimated to affect 27-69 million individuals yearly with the bulk of the TBI burden in low-to-middle income countries (LMICs). Research has highlighted significant between-hospital variability in TBI outcomes following emergency surgery, but the overall incidence and epidemiology of TBI remains unclear. To address this need, we established the Global Epidemiology and Outcomes following Traumatic Brain Injury (GEO-TBI) registry, enabling recording of all TBI cases requiring admission irrespective of surgical treatment.

Objective

The GEO-TBI: Incidence study aims to describe TBI epidemiology and outcomes according to development indices, and to highlight best practices to facilitate further comparative research.

Design

Multi-centre, international, registry-based, prospective cohort study.

Subjects

Any unit managing TBI and participating in the GEO-TBI registry will be eligible to join the study. Each unit will select a 90-day study period. All TBI patients meeting the registry inclusion criteria (neurosurgical/ICU admission or neurosurgical operation) during the selected study period will be included in the GEO-TBI: Incidence.

Methods

All units will form a study team, that will gain local approval, identify eligible patients and input data. Data will be collected via the secure registry platform and validated after collection. Identifiers may be collected if required for local utility in accordance with the GEO-TBI protocol.

Data

Data related to initial presentation, interventions and short-term outcomes will be collected in line with the GEO-TBI core dataset, developed following consensus from an iterative survey and feedback process. Patient demographics, injury details, timing and nature of interventions and post-injury care will be collected alongside associated complications. The primary outcome measures for the study will be the Glasgow Outcome at Discharge Scale (GODS) and 14-day mortality. Secondary outcome measures will be mortality and extended Glasgow Outcome Scale (GOSE) at the most recent follow-up timepoint.

Women in Neurosurgery: Historical Path to Self-Segregation and Proposal for an Integrated Future

Despite the rising percentage of women accessing the medical profession over the last few decades, surgical specialties are still largely male-dominated; in particular, a remarkable gender disparity is evident in neurosurgery, where only 19% of practitioners are females. Although women may be reluctant to choose a challenging specialty like neurosurgery due to concerns around how to balance family and career, it must be admitted that prejudices against female neurosurgeons have been deeply rooted for long, prompting many to give up and switch track to less demanding subspecialties. Among those who have persisted, many, if not most, have experienced difficulties in career progression and received unequal treatment in comparison with their male counterparts. In 1989, a group of 8 female neurosurgeons founded Women in Neurosurgery (WINS), an organization that aimed to guarantee inclusivity in neurosurgery, encouraging a better and more egalitarian working environment. Thereafter, WINS sessions were regularly promoted at international conferences, offering female neurosurgeons a platform to report issues related to gender discrimination. Over recent years, the mission of WINS sessions in national and international conferences has taken an unexpected deviation; they have progressively become supplementary scientific sessions with only women neurosurgeons as speakers, thus paving the road to a form of self-segregation. This tendency has also resulted in the establishment of sections of only female neurosurgeons within some national societies. Although there remains a faction that fiercely supports the WINS mindset of reserved spaces for women, such segregation is an upsetting prospect for those who believe that science and professionalism have no gender; a growing part of the global neurosurgical community believes that the conception of a “female neurosurgery” and a “male neurosurgery” is misguided and counterproductive and consider the existence of the WINS as anachronistic and no longer necessary.

Posterior Circulation Intervention but Mind the Spinal Cord!

Spinal cord infarction (SCI), a rare complication following endovascular treatment of posterior circulation aneurysms, is infrequently recognized in the periprocedural period. We illustrate the same with digital subtraction angiography and diffusion-weighted magnetic resonance imaging in this series of two cases. Categorically, the anterior spinal artery was patent, post-procedure, in both instances. Likely, guiding catheter-induced local flow alterations initiates the pathogenesis. A subsequent insufficiency of radiculomedullary artery (RMA) reinforcements is the probable mechanism leading to hemodynamic compromise. Our observations further reiterate that periprocedural antiplatelet therapy is conceivably ineffective in preventing SCI. Besides, advanced age and uncontrolled hypertension could potentially exacerbate the periprocedural RMA compromise. Due vigilance is required to recognize this rare and potentially life-threatening complication in posterior circulation neurovascular intervention.

Complex Chiari Malformation: Proposal of a New Set of Diagnostic Criteria and Outcomes After fusion Surgery

BACKGROUND

The proposal of C1-C2 fusion as a better treatment option compared with foramen magnum decompression (FMD) for the treatment of Chiari 1 malformations has led to controversy. Although FMD is a time-tested treatment option, a group of patients exists who will benefit from C1-C2 fusion. We have proposed an objective system for defining complex Chiari malformations and studied the outcomes of fusion with decompression versus decompression alone for these patients.

METHODS

A total of 26 patients with complex Chiari malformations were identified using our criteria (any 4 of 7 clinicoradiological parameters). Of the 26 patients, 13 had undergone C1-C2 fusion with FMD and 13 had undergone FMD alone. They had also undergone pre- and postoperative clinicoradiological evaluations, and the outcomes were assessed using the Chicago Chiari outcome score.

RESULTS

Of the 13 patients in the fusion group, 12 (92.3%) showed improvement compared with only 6 of 13 patients (46.2%) in the nonfusion group using the Chicago Chiari outcome score, a statistically significant difference (P = 0.036, χ² test). The mean hospital length of stay was longer for the fusion group (6.15 ± 1.46 days) than for the nonfusion group (4.38 ± 2.22 days; P = 0.02).

CONCLUSIONS

We have proposed a novel set of criteria for defining complex Chiari malformations. Fusion with decompression provided better outcomes than decompression alone.

Functional cortical reorganization in cases of cervical spondylotic myelopathy and changes associated with surgery

OBJECTIVE The physiological mechanisms underlying the recovery of motor function after cervical spondylotic myelopathy (CSM) surgery are poorly understood. Neuronal plasticity allows neurons to compensate for injury and disease and to adjust their activities in response to new situations or changes in their environment. Cortical reorganization as well as improvement in corticospinal conduction happens during motor recovery after stroke and spinal cord injury. In this study the authors aimed to understand the cortical changes that occur due to CSM and following CSM surgery and to correlate these changes with functional recovery by using blood oxygen level-dependent (BOLD) functional MRI (fMRI). METHODS Twenty-two patients having symptoms related to cervical cord compression due to spondylotic changes along with 12 age- and sex-matched healthy controls were included in this study. Patients underwent cervical spine MRI and BOLD fMRI at 1 month before surgery (baseline) and 6 months after surgery. RESULTS Five patients were excluded from analysis because of technical problems; thus, 17 patients made up the study cohort. The mean overall modified Japanese Orthopaedic Association score improved in patients following surgery. Mean upper-extremity, lower-extremity, and sensory scores improved significantly. In the preoperative patient group the volume of activation (VOA) was significantly higher than that in controls. The VOA after surgery was reduced as compared with that before surgery, although it remained higher than that in the control group. In the preoperative patient group, activations were noted only in the left precentral gyrus (PrCG). In the postoperative group, activations were seen in the left postcentral gyrus (PoCG), as well as the PrCG and premotor and supplementary motor cortices. In postoperative group, the VOA was higher in both the PrCG and PoCG as compared with those in the control group. CONCLUSIONS There is over-recruitment of sensorimotor cortices during nondexterous relative to dexterous movements before surgery. After surgery, there was recruitment of other cortical areas such as the PoCG and premotor and supplementary motor cortices, which correlated with improvement in dexterity, but activation in these areas was greater than that found in controls. The results show that improvement in dexterity and finer movements of the upper limbs is associated with recruitment areas other than the premotor cortex to compensate for the damage in the cervical spinal cord.

Craniofacial injuries in professional cricket: no more a red herring

The issue of head injury in a noncontact sport like cricket is a matter of great debate and it carries more questions than answers. Recent incidents of fatal head injuries in individuals wearing a helmet have caused some to question the protective value of the helmet. The authors discuss the pattern, type of injury, incidents, and location of cranio-facio-ocular injuries in professional cricket to date. They evaluate the history of usage of the helmet in cricket, changes in design, and the protective value, and they compare the efficacy of various sports' helmets with injury profiles similar to those in cricket. The drop test and air cannon test are compared for impact energy attenuation performance of cricket helmets. A total of 36 cases of head injuries were identified, of which 5 (14%) were fatal and 9 (22%) were career-terminating events. Batsmen are the most vulnerable to injury, bearing 86% of the burden, followed by wicketkeepers (8%) and fielders (5.5%). In 53% of cases, the ball directly hit the head, while in 19.5% of cases the ball entered the gap between the peak and the faceguard. Ocular injuries to 3 wicketkeepers proved to be career-terminating injuries. The air cannon test is a better test for evaluating cricket helmets than the drop test. Craniofacial injuries are more common than popularly believed. There is an urgent need to improve the efficacy and compliance of protective restraints in cricket. A strict injury surveillance system with universal acceptance is needed to identify the burden of injuries and modes for their prevention.

Subclinical respiratory dysfunction in chronic cervical cord compression: a pulmonary function test correlation

OBJECTIVE

Respiratory abnormalities are well documented in acute spinal cord injury; however, the literature available for respiratory dysfunction in chronic compressive myelopathy (CCM) is limited. Respiratory dysfunction in CCM is often subtle and subclinical. The authors studied the pattern of respiratory dysfunction in patients with chronic cord compression by using spirometry, and the clinical and surgical implications of this dysfunction. In this study they also attempted to address the postoperative respiratory function in these patients.

METHODS

A prospective study was done in 30 patients in whom cervical CCM due to either cervical spondylosis or ossification of the posterior longitudinal ligament (OPLL) was diagnosed. Thirty age-matched healthy volunteers were recruited as controls. None of the patients included in the study had any symptoms or signs of respiratory dysfunction. After clinical and radiological diagnosis, all patients underwent pulmonary function tests (PFTs) performed using a standardized Spirometry Kit Micro before and after surgery. The data were analyzed using Statistical Software SPSS version 13.0. Comparison between the 2 groups was done using the Student t-test. The Pearson correlation coefficient was used for PFT results and Nurick classification scores. A p value < 0.05 was considered significant.

RESULTS

Cervical spondylotic myelopathy (prolapsed intervertebral disc) was the predominant cause of compression (n = 21, 70%) followed by OPLL (n = 9, 30%). The average patient age was 45.06 years. Degenerative cervical spine disease has a relatively younger onset in the Indian population. The majority of the patients (n = 28, 93.3%) had compression at or above the C-5 level. Ten patients (33.3%) underwent an anterior approach and discectomy, 11 patients (36.7%) underwent decompressive laminectomy, and the remaining 9 underwent either corpectomy with fusion or laminoplasty.

The mean preoperative forced vital capacity (FVC) (65%) of the patients was significantly lower than that of the controls (88%) (p < 0.001). The mean postoperative FVC (73.7%) in the patients showed significant improvement compared with the preoperative values (p = 0.003). The mean postoperative FVC was still significantly lower than the control value (p = 0.002). The mean preoperative forced expiratory volume in 1 second (FEV1) (72%) of the patients was significantly lower than that of the controls (96%) (p < 0.001). The mean postoperative FEV1 (75.3%) in the cases showed no significant improvement compared with the preoperative values (p = 0.212). The mean postoperative FEV1 was still significantly lower than the control value (p < 0.001). The mean postoperative FEV1/FVC was not significantly different from the control value (p = 0.204). The mean postoperative peak expiratory flow rate was significantly lower than the control value (p = 0.01). The mean postoperative maximal voluntary ventilation was still significantly lower than the control value (p < 0.001). On correlating the FVC and Nurick scores using the Pearson correlation coefficient, a negative correlation was found.

CONCLUSIONS

There is subclinical respiratory dysfunction and significant impairment of various lung capacities in patients with CCM. The FVC showed significant improvement postoperatively. Respiratory function needs to be evaluated and monitored to avoid potential respiratory complications.

Surgical management of petroclival meningiomas: Factors affecting early post-operative outcome

INTRODUCTION

Petroclival meningiomas pose a major challenge to the treating neurosurgeon. The philosophy of treatment has changed over the decades from a nihilistic attitude to that of aggressive total excision to now a more tempered, maximal safe excision preventing morbidity followed by adjuvant treatment. Despite the advances in neurosurgery, surgical management of these tumours is still associated with sizable morbidity and mortality.

MATERIAL AND METHODS

This is a retrospective study of surgically managed petroclival meningiomas at our institute. Clinical status, radiological features and surgical outcome were analysed.

RESULTS

Between January 2003 and August 2013, we have operated on 30 patients. The most common presenting complaints were varying degrees of cranial nerve involvement and cerebellar dysfunction. Surgery was done using one of the skull base approaches with the retrosigmoid approach being used maximally (22 cases). Total or near-total excision was possible in 11 cases. There was a post-operative deterioration in cranial nerve functions in all patients and deterioration in Karnofsky Performance Score in seven patients at discharge. Three improved to independent status on follow-up. There was mortality in two cases. Overall 23 of the 30 patients (76.6%) had favourable outcomes.

CONCLUSIONS

These are challenging tumours to treat and are associated with sizable morbidity and mortality. On statistical analysis, we found that if the tumour has a size of 3-5 cm and petroclival in location with no sphenoid extension and the lesion is homogenous on T2-weighted images, then there was a trend towards gross total resection and favourable outcome.

Silent Epidemic: The Effects of Neurofeedback on Quality-of-Life

BACKGROUND

The complex interaction of human, vehicle and environmental factors along with a lack of sustainable preventive programs has contributed to the "silent epidemic" of traumatic brain injuries (TBI). TBI poses a grave threat to the quality-of-life (QOL).

AIM

The aim of the present study was to examine the effects of neurofeedback in QOL in patients with TBI.

MATERIALS AND METHODS

Pre- and post-interventional study design was adopted. Sixty patients, 30 in the intervention group (IG) and 30 in waitlist group with the diagnosis of TBI in the age range of 18-49 years were assessed on QOL scale, after obtaining the informed consent. Patients in the IG were given 20 sessions of alpha-theta neurofeedback training (NFT), 5 sessions / week.

STATISTICS ANALYSIS

Descriptive statistics, Spearman's correlation, Mann-Whitney and Chi-squared test was used.

RESULTS AND CONCLUSION

Patients in the IG showed statistical improvements in QOL post post-neurofeedback. Results are encouraging for the incorporation of NFT into treatment programs for patients with TBI in improving QOL.

Congenital anomalies at the craniovertebral junction-posterior fossa region: report of two cases

BACKGROUND

Various combinations of bony and soft tissue anomalies have been described at the craniovertebral junction (CVJ). These include posterior fossa dermoids (with or without dermal sinuses) associated with Klippel-Feil anomalies and dermoids (no previous reports of overlying dermal sinuses) associated with bony anomalies.

PATIENTS

Two patients with a combination of CVJ anomalies are described.

RESULTS

Both patients had a posterior fossa dermoid, dermal sinus, and occipitalized C1 arch. Furthermore, one patient had a complex bony CVJ anomaly, and the other had a Klippel-Feil anomaly in addition. The clinical presentation and management are elucidated.

CONCLUSIONS

Patients who present with any one of these lesions need to be evaluated for the existence of other congenital anomalies. These are complex malformations to treat.

BAY 61-3606, CDKi, and sodium butyrate treatments alter gene expression in human vestibular schwannomas and cause cell death in vitro

Background:

Disrupted kinase and signaling pathways are found in many human cancers and they are implicated in carcinogenesis. Therefore, kinases have been important targets for the development of cancer therapeutics. Human vestibular schwannomas (VS) are the third most common intracranial tumours which occur in the vestibular branch of VIII^th cranial nerve. Sodium butyrate (Na-Bu) is a potent histone deacetylase inhibitor (HDACi) and with therapeutic efficacy. Spleen tyrosine kinase (Syk) has been implicated in many immunological consequences and is a putative target for cancer treatment.

Aims and objectives:

The present study was undertaken in order to evaluate the effect Na-Bu, 2,4-Diamino-5-oxo-pyrimidine hydrochloride (CDKi), a broad spectrum kinase inhibitor and BAY 61-3606 (Syk inhibitor) on the survival of VS tumour tissues in vitro and their possible effects on cell survival/death and levels of a few key proteins in the treated cells as compared to the untreated cells.

Materials and methods

Fresh tumour tissues were collected randomly from 16 patients with sporadic, VS tumours, minced into pieces and maintained in primary cultures. Twenty four hours later these cells were exposed to Na-Bu, BAY 61-3606 or CDKi. Forty eight hours after exposure, the tissue lysates were analysed by western blotting for expression of pRb and other proteins involved in cell survival/death.

Summary and significance of the findings:

The tissue samples used were positive for S100A protein, the maker for schwann cells confirming the VS tumour samples. The three individual treatments led to morphological change, DNA fragmentation and cell death and significantly reduced level of total and phosphorylated forms of pRb protein and drastically reduced EGF-R protein. These treatments also modulated levels of other proteins involved in cell survival/death such as PI3K, Caspase 3, TGF-β1, JNK, ASK1, Shh, NF-κB, p21^cip1/waf1. The Untreated cells had uncleaved PARP-1 protein and the treated cells had cleaved PARP-1. The results show that the observed cell death in treated cells perhaps is mediated by modulation of the levels and processing of certain key proteins. The possible development of these components as therapeutics is discussed.

Multicompartmental trigeminal schwannomas: management strategies and outcome

Trigeminal schwannomas (TS), though the second most common intracranial schwannomas, represent only 0.8 to 8% of all Schwannomas. Advancement in imaging and microsurgical techniques has led to a remarkable improvement in the outcome of these benign tumors. Multicompartmental TS, though extensive, have an excellent outcome after surgery. In this article, we present our experience in the management of multicompartmental TS (types middle/posterior [MP], middle/extracranial [ME], and middle/posterior and extracranial [MPE]) and outcome in this rather uncommon group of tumors. This retrospective study included all the cases of multicompartmental TS operated at our institute from 1999 to 2009. The medical data were analyzed retrospectively. The demographic profile, clinical features, radiological findings, management strategies, postoperative complications, length of hospitalization, and outcome were noted. Follow-up data were collected from outpatient department records. The range and average duration of follow-up were noted. There were a total of 43 patients with TS operated over this period. Among them, 4 were type B, 5 type C, 11 type D, 18 type E, and 5 type F. The study included 26 patients (4 type B, 18 type E, and 4 type B). A variety of approaches were used to approach the tumor. Of 26, 23 patients had a gross total or near-total excision while 2 patients were lost to follow-up. Among the three patients who had a near-total excision and follow-up magnetic resonance imaging showed a small residual tumor, two are on close follow-up with no increase in the size of the tumor over a follow-up period of 3 years, the other patient is a 5-year-old boy who is too young for radiosurgery and is on follow-up. There was no mortality while four patients have had fresh permanent postoperative deficits. Multicompartmental TS are a rare, complex but eminently treatable group of tumors. A variety of surgical approaches can be used to excise the tumor. The choice of approach needs to be individualized with total excision providing excellent results.

An unusual infection, an unusual outcome--Fonsecaea pedrosoi cerebral granuloma

Phaeohyphomycosis is caused by pigmented fungi that are not normally pathogenic. Fonsecaea is a rare cause of cerebral infections, most of which are caused by F. monophora. Brain infections caused by F. pedrosoi are very rare, and there are only a few case reports describing this. Most infections take the form of abscesses (epidural or intracerebral). The authors report a rare case of a contained fungal granuloma caused by F. pedrosoi. The patient presented with epilepsy, which was treated as a case of extratemporal lesion-related epilepsy. The diagnosis was made after resection. The authors describe the clinical course of this patient.

Posterior fossa subdural empyema in children--management and outcome

AIMS

The aims of this study were to analyze the clinical features, radiologic findings, bacteriologic spectrum, and management protocols and outcomes in posterior fossa subdural empyemas in children.

MATERIALS AND METHODS

This study is a retrospective analysis of all children (age, <18 years) treated over a ten-year period (1994-2004) at NIMHANS, India. Clinical, bacteriologic, radiologic, and follow-up data were analyzed.

RESULTS

Twenty-seven children with posterior fossa empyemas were treated during this period, making this the largest series to date dealing with this rare entity. Posterior fossa empyemas are seen more commonly in the summer months and in males. Of the patients, 74.1% were in altered sensorium. The clinical features included the triad of fever, headache, and vomiting, which is a nonspecific picture. Cerebellar signs were elicited only in 40%. The most common source was untreated middle ear infection. Pus usually accumulates over the cerebellar convexity and is associated with hydrocephalus in 74% of patients. Cultures of the empyema pus were positive in 74% of cases, and 18.5% had polymicrobial infections. Only 21% of the patients needed a permanent CSF diversion procedure. Craniectomy is the treatment of choice in these cases.

CONCLUSIONS

The clinical features are nonspecific. Early surgery can salvage most patients and obviate the need for permanent CSF diversion procedures. Surgery (evacuation of empyema and mastoidectomy), antibiotics, and management of hydrocephalus are the mainstays of treatment.

Histological and immunohistochemical characterization of AT/RT: a report of 15 cases from India

Atypical teratoid rhabdoid tumor (AT/RT) is a highly malignant embryonal CNS tumor, generally unresponsive to any form of therapy, uniformly fatal within 1 year. We report 15 cases of AT/RT diagnosed at our center over a period of 5 years (2003-08). Tumors were located in different sites of the neuraxis, posterior fossa being the most common (n = 10) followed by cerebral lobes (n = 3). There was one each at the supra sellar and cervical spinal regions, respectively. Radiologically most of the tumors were heterodense and enhancing heterogeneously. The tumors exhibited diverse histological profile that included rhabdoid and PNET areas in all cases, mesenchymal and epithelial areas in 73.3% and 53.3% cases, respectively. Necrosis was evident in all cases and one showed calcification. Tumor cells displayed a polyphenotypic immunoprofile. All cases were consistently positive for vimentin and epithelial membrane antigen and were negative for desmin. Variable positivity was seen for other markers. The number of cases positive for these were: CK (53%), SMA (60%), synaptophysin (66%), NFP (33.3%) and GFAP (85%). CK staining was prominent in epithelial areas, while PNET cells labeled prominently with synaptophysin. There was lack of INI1 expression in all cases. Follow-up was available in 46.6% of cases which revealed a uniform poor prognosis.

Spinal osteochondroma: spectrum of a rare disease

✓Osteochondromas are the most common benign bone tumor. Although the metaphysial region of long bones is the usual site of these tumors, the vertebrae may be infrequently affected. The presentation may vary from typical compressive myelopathy to radiculopathy or radiculomyelopathy, depending on the site of involvement. The authors present 3 consecutive cases of cervical spine osteochondromas encountered over 3 years at their institution, each different in its site of involvement, presentation, and chosen treatment. The patient in Case 1 had the typical presentation and lesion site, and was treated with a conventional laminectomy. The patient in Case 2 presented with an extensive disease that required complex, staged surgery with spinal fusion and instrumentation. The patient in Case 3 presented with monoradiculopathy and had a facet joint osteochondroma that was successfully treated with a simple partial facetectomy, without laminectomy.