Bhagavatula Indira Devi

Pathological spectrum of neuronal/glioneuronal tumors from a tertiary referral neurological Institute.

Neuronal/glioneuronal tumors are uncommon neoplasms of the CNS with frequent association with refractory epilepsy. Reports documenting the entire spectrum of neuronal/glioneuronal tumors are scarce in the literature. Zulch et al. from Germany in a large series reported that neuronal/glioneuronal tumors accounted for 0.4% (38/9000 cases) of all brain tumors, with similar incidence reported from Japan (0.4%), with higher incidence from Korea (2.1%). However, data from the Indian subcontinent are lacking. We reviewed 244 cases of neuronal/glioneuronal tumors of the CNS diagnosed over the last decade at our Institute and they constituted 0.86% of all CNS tumors (244/28061) received in that period. Mean age at presentation was 25.06 years (range: 1–75 years) with male preponderance (M : F = 1.54 : 1). The majority occurred in third decade (76 cases, 31.4%), with only few cases occurring beyond fifth decade (13 cases, 5.3%). Ganglioglioma/gangliocytoma (94 cases, 38.52%) was the most frequent followed by central neurocytoma (86 cases, 35.24%), paraganglioma (32 cases, 13.52%), dysembryoplastic neuroepithelial tumors (DNET) (21 cases, 8.6%), desmoplastic infantile astrocytoma/desmoplastic infantile ganglioglioma (DIA/DIG) (6 cases, 2.45%), papillary glioneuronal tumor (PGNT) (3 cases, 1.22%) and rosette‐forming glioneuronal tumor (RGNT) (1 case, 0.4%). Association with seizures was noted in 40.95% of cases. Glioneuronal tumors are an expanding group of tumors with varying spectra of morphologic patterns and biological behavior. An improved understanding has direct clinical implications for optimizing current treatments and developing novel therapeutic approaches. Although most glioneuronal tumors carry a favorable prognosis, other factors such as inaccessibility to surgical resection and rarely, malignant transformation, make it difficult to accurately predict the biological behavior based on histopathology alone. Reliable prognostic markers remain to be defined.

Cortical reorganization following neurotization: a diffusion tensor imaging and functional magnetic resonance imaging study.

BACKGROUND Following successful intercostal-musculocutaneous nerve (ICN-MCN) neurotization for brachial plexus injuries (BPIs), patients initially show a synkinetic movement of elbow flexion during inspiration. Later they are able to flex the elbow, independent of respiratory activity. OBJECTIVE To demonstrate cortical reorganization following ICN-MCN coaptation in BPI through functional magnetic resonance imaging (fMRI) and diffusion tensor imaging (DTI). METHODS Thirty adult patients underwent ICN-MCN coaptation for BPI. The controls were age and sex matched. All patients had Sunderland 3 or 4 degree of injury. Patients underwent fMRI and DTI (pre- and postoperatively) with electromyography of the biceps. Maps of neural activity within the motor cortex were generated in the paralyzed and control arms and center of maximum activity was calculated. Fractional anisotropy and apparent diffusion coefficient were generated from fMRI and DTI over the motor cortex and comparison was made between the paralyzed and control arms. RESULTS Median deinnervation interval was 6 months. Seventeen patients improved from grade 0 to grade 3 or more. There was no significant difference between the coordinates for maximum activity, when the cortical activity following elbow flexion of the patients who improved was compared with the control arm activity. There was reduction in FA and ADC values in patients who have improved following surgery when compared to controls. Fractional anisotropy and apparent diffusion coefficient values of the postoperative patients revealed no significant difference from the controls or preoperative patients. CONCLUSION Cortical plasticity following ICN-MCN transfer in BPI does occur. There was no correlation between the degree of improvement either with the transposition of activity on the motor cortex from the chest to the elbow area, or the amount of activity on the motor cortex representing the elbow area.

EEG Neurofeedback therapy: Can it attenuate brain changes in TBI?

BACKGROUND Electroencephalogram Neurofeedback therapy (EEG-NFT) has several potential beneficial effects in terms of improving cognition and electrophysiological regulation among patients with brain injury. However, in vivo structural and functional changes remain less explored. OBJECTIVE The aim of the present study is to explore EEG-NFT induced in vivo changes in traumatic brain injury (TBI) patients. METHOD Two patients with mean age of 15 years with moderate head injury who had more than seven post concussion symptoms and poor cognitive performances (<5 percentile) were subjected to 20 sessions of EEG-NFT. The neuropsychological test scores, post concussion symptoms and MRI scan of the brain were recorded pre-post to EEG-NFT. RESULTS During EEG-NFT the cognitive scores and concussion symptoms improved significantly (p < 0.05). The EEG-NFT has shown significant increase in cortical grey matter (GM) volumes (p < 0.0001) and fractional anisotropy (FA) of cortical white matter (WM) tracts (p < 0.0001, voxel max 60 and above). There was a significant decrease in global, local efficiency, cost and clustering coefficient of functional connectivity (Wilcoxon Sign Rank Test p < 0.05). Interestingly there was a significant increase in thalamo-cortical connection (increase FA value) after EEG-NFT. CONCLUSION The EEG-NFT therapy has shown significant changes in structural and functional connectivity among young moderately injured TBI patients.

Does isolated traumatic subarachnoid hemorrhage affect outcome in patients with mild traumatic brain injury

Background:The importance of isolated traumatic subarachnoid hemorrhage (SAH) in relation to functional outcome in patients with mild traumatic brain injury (TBI) has not been frequently studied. The aim of this study was to compare the impact of isolated SAH with normal computed tomographic (CT) scan on outcome of patients with mild TBI. Methods:This is a retrospective study of clinical records and CT scans of all patients with mild TBI (Glasgow Coma Scale score ≥13) evaluated from January 1, 2010, to March 15, 2010, at our institution. The patients were divided into 2 groups: isolated SAH and normal CT scan. The telephonic Glasgow Outcome Scale–Extended, Rivermead Post-Concussion Symptoms Questionnaire (RPCSQ), and Rivermead Head Injury Follow-up Questionnaire (RHFUQ) scores were used to assess outcome after 1 year of injury. Independent sample t test in SPSS was used to assess difference in outcome. Results:A total of 1149 patients with mild TBI were evaluated during study period. Among them, 34 (2.9%) patients had isolated SAH. Twenty-eight patients were male and 6 were female, with a mean age of 36.5 years. Subarachnoid hemorrhage was cortical in 19 (55.9%) patients, interhemispheric in 3 (8.8%) patients, Sylvian fissure in 2 (5.9%) patients, and basal cisternal in 1 (2.9%) patient. Nine (26.5%) patients had SAH at multiple locations. The mean RPCSQ and RHFUQ scores for patients with isolated SAH were 1.38 ± 2.40 and 1.11 ±3.305, respectively. The mean RPCSQ and RHFUQ scores for patients with normal CT scans were 0.40 ± 1.549 and 0.533 ± 1.59, respectively. There was no significant difference in the outcome scores between the SAH and the normal CT scan groups (RHFUQ, P = .45; RPCSQ, P = .248). Conclusion:In our study sample of patients with mild TBI, there is no difference in outcome of patients with isolated SAH compared with those with normal CT scans 1 year after injury.

Mixed-density extradural hematomas on computed tomography-prognostic significance

BACKGROUND It has been variably reported that patients who acutely present with low- or mixed-density blood on CT scan are associated with poor clinical outcome. The aim of the study was to correlate the presence or absence of mixed density within EDHs on CT scanning with the clinical outcome. METHODS This is a retrospective study of a total of 109 patients with EDHs who were operated on from August 2001 to August 2002. The CT scans were reviewed and classified into 2 categories-predominantly hyperdense and mixed density. This was correlated with clinical details and outcome. RESULTS In all, 43.2% (16/37) of patients in the mixed-density category presented with GCS of no more than 8 as compared with 23.6% (17/72) of patients in the hyperdense group (P < .05). Mean hematoma volume in the mixed-density group was 72 cm(3) as compared with 42 cm(3) in the hyperdense group (P < .05). Mortality rate was significantly higher in the mixed-density category (21.6% vs 4.2%, P < .05). CONCLUSION The study portends mixed density in EDH as a potent poor prognostic indicator. The mixed density of the clot probably indicates that the clot is rapidly increasing in size and requires even earlier and more aggressive treatment.

An equiosmolar study on early intracranial physiology and long term outcome in severe traumatic brain injury comparing mannitol and hypertonic saline.

The impact of hypertonic saline (HTS) on long term control of intracranial hypertension (ICH) is yet to be established. The current prospective randomized controlled study was carried out in 38 patients with severe traumatic brain injury (TBI). Over 450 episodes of refractory ICH were treated with equiosmolar boluses of 20% mannitol in 20 patients and 3.0% HTS in 18 subjects. Intracranial pressure (ICP) was monitored for 6days. ICP and cerebral perfusion pressure (CPP) were comparable between the groups. The mannitol group had a progressive increase in the ICP over the study period (p=0.01). A similar increase was not seen in the HTS group (p=0.1). The percentage time for which the ICP remained below a threshold of 20 mmHg on day6 was higher in the HTS group (63% versus 49%; p=0.3). The duration of inotrope requirement in the HTS group was less compared to the mannitol group (p=0.06). The slope of fall in ICP in response to a bolus dose at a given baseline value of ICP was higher with HTS compared to mannitol (p=0.0001). In-hospital mortality tended to be lower in the HTS group (3 versus 10; p=0.07) while mortality at 6 months was not different between the groups (6 versus 10; p=0.41). Dichotomized Glasgow Outcome Scale scores at 6months were comparable between the groups (p=0.21). To conclude, immediate physiological advantages seen with HTS over mannitol did not translate into long term benefit on ICP/CPP control or mortality of patients with TBI.

Anterior communicating artery aneurysm presenting with vision loss.

Anterior communicating artery aneurysm rarely presents with symptoms of compression of anterior visual pathways. We report a case of 65 years old man, who had complete loss of vision in right eye and temporal hemianopsia in left eye due to giant anterior communicating artery aneurysm.

Traumatic brain injury: Does gender influence outcomes?

Background: Traumatic brain injury (TBI) is a major public health problem. Both genders are affected, but little is known about female TBI. The present study exclusively explores epidemiological, clinical, imaging, and death aspects of female TBI, and how it differs from males. Methods: It is a retrospective study. Data were documented from a tertiary institute during January 2010 to March 2010. All variables were documented on standard proforma. The data were analyzed using R statistics software. Age group was categorized into pediatric (<18 years), middle (19–60 years) and elderly (>61 years). Significance was tested using Chi-square test at the significance level ofP< 0.05. Results: Data of 1627 TBI patients were recorded. Of the total, female TBIs contributed nearly 20%. Compared to males, female patients reported higher percentages in manifesting symptoms (84.3% vs. 82.6%), injuries due to fall (32.1% vs. 24.4%), and surgical interventions (11.6% vs. 10.4%). Female patients were significantly higher in mild head injury group (76.8% vs. 69.5%, P - 0.016) and mortality (3.4% vs. 1.6%, P - 0.048). Number of patients and deaths was more among females than males in pediatric and elderly age group. Severities of injuries were more among female patients than male patients in middle and elder age groups. Conclusion: The study results observe that female TBI group differ significantly in the severity of injury and mortality.

Bicycle accident-related head injuries in India

Objectives: To describe the epidemiology of head injuries sustained due to bicycle accidents in India. Materials and Methods: Data were retrospectively collected over a period of six months (15 May 2011 to 15 November 2011). Demography of patients, Glasgow coma scale (GCS), clinical and imaging findings, and mortality and outcome using Glasgow outcome scale (GOS), Rivermead post-concussion symptom questionnaire (RPCSQ) and Rivermead head injury follow-up questionnaire (RHFUQ), were analyzed. Outcome was assessed by telephonic interview. Results: There were 108 patients (100 males) with mean age of 27.7 years. Seventy-four (68.5%) were from rural areas. Accidents due to vehicular collision accounted for 60 (55.6%) cases. None wore a helmet. The admission GCS was 14-15 in 68.5% cases, 13-3 in 31.5%. The risk of moderate to severe injuries was increased among working laborers (OR = 5), and patients with loss of consciousness (OR = 4). Sixty-three (49%) patients had abnormal computed tomography (CT) findings; most common finding was skull fracture 25 (23.1%). Four patients needed surgery. The GOS assessment at three to six months revealed favorable outcome in 66 patients (61.1%) and death in 8 (7.4%). The common post-concussion symptoms were headache, fatigue, and poor concentration. Conclusion: The majority of hospitalized cyclists were from a rural background and of the lower income group. After three months the majority of patients had good recovery with few persistent concussion symptoms.

Unusual complications of a benign tumour – our experience with midline posterior fossa epidermoids

Abstract Epidermoids of the brain are uncommon benign tumours. Their midline posterior fossa location is exceedingly rare. Fifteen patients with this condition were operated during a 14-year period. Majority of the patients presented in their middle age with mean duration of symptoms of 10 months. Gait imbalance was the commonest symptom observed. Seven patients had features suggestive of raised intracranial tension. Computed tomography scanning showed typical hypodense lesions. On MRI, tumours were hypo-intense on T1 weighted images and hyper-intense on T2 weighted images. All patients underwent microsurgical excision. We encountered certain complications in the post-operative period. This prompted us for a review of our case material and literature and is the basis of the present article. Implications of these findings are discussed.