Deepa Danan

Psychiatric manifestations of brain tumors: diagnostic implications

Brain tumors can cause any type of psychiatric symptoms. Rarely, brain tumors can present without any localizing signs but with psychiatric symptoms. A review of the literature indicates that there is no association between psychiatric symptoms and tumor location or histological type. Hence, it is important for clinicians to have an index of suspicion of brain tumor in patients with new-onset psychiatric symptoms, atypical presentations and treatment resistance and, as a result, consider neuroimaging. Early detection is of paramount importance for treatment and quality of life of patients. Mood symptoms may herald a brain tumor. For example, anorexia can be a presenting symptom of hypothalamic tumors. A prospective controlled study will be of benefit to further assess the association between psychiatric symptoms and brain tumor locations. New developments in the diagnostic and treatment area of brain tumors would be of help in undertaking such a prospective study.

Brain Tumor and Psychiatric Manifestations: A Case Report and Brief Review

Brain tumors may present multiple psychiatric symptoms such as depression, personality change, abulia, auditory and visual hallucinations, mania, panic attacks, or amnesia. A case of a 79-year-old woman who presented with depressive symptoms but showed minimal neurological signs and symptoms is discussed. Neuroimaging revealed a brain tumor in the left parietal lobe, and patient underwent neurosurgical treatment and subsequently received chemotherapy and radiation. Some patients with neurologically silent brain tumors may present with psychiatric symptoms only. Therefore, we emphasize the consideration of neuroimaging in patients with a change in mental status regardless of a lack of neurological symptoms.

Brain tumor location and psychiatric symptoms: is there any association? A meta-analysis of published case studies

A meta-analytic study of reports of brain tumors and psychiatric symptoms for the past 50 years was conducted to examine potential associations between tumor location and psychiatric symptoms. Results demonstrated that there is a statistically significant association between anorexia symptoms and hypothalamic tumors. For the rest of the brain regions a statistically significant association could not be definitively determined. However, several of the regions demonstrated an increased likelihood of associated symptoms when compared with other regions. The methodological limitations of this analysis are discussed.

Prognostic value of albumin in patients with head and neck cancer

Albumin is an indicator of nutritional status and has been investigated as a predictor of cancer survival and perioperative outcomes. This study investigated the prognostic value of preoperative serum albumin in surgical patients with head and neck cancer (HNC).

Impact of blood transfusions on patients with head and neck cancer undergoing free tissue transfer

To determine whether blood transfusions are associated with adverse outcomes in patients with head and neck cancer (HNC) undergoing microvascular free tissue transfer.

Intra-abdominal vascular injury during trocar-assisted ventriculoperitoneal shunting: case report.

OBJECTIVELaparoscopic trocar injury is a relatively well-described complication of cholecystectomies and gynecological procedures. However, this type of injury has not been reported in association with adult neurological surgery. To increase awareness of this very serious risk, we report a case of intra-abdominal vascular injury during a shunt procedure involved with a common neurosurgical procedure. CLINICAL PRESENTATIONA 76-year-old man with no previous abdominal surgical history presented with probable normal pressure hydrocephalus. INTERVENTIONAfter an appropriate preoperative workup confirming probable normal pressure hydrocephalus, the patient consented to placement of a ventriculoperitoneal shunt with a programmable valve. During placement of the distal catheter using an abdominal trocar, the aorta was punctured inadvertently, necessitating emergency laparotomy for vascular repair. CONCLUSIONAn abdominal trocar should be used with caution in ventriculoperitoneal shunt surgery. Even with meticulous technique, vascular injury can occur with any trocar-based abdominal procedure. The neurosurgeon who uses this technique must be prepared to initiate emergent vascular access and repair, with a vascular surgery team available should such an injury occur. Alternatively, open placement of peritoneal catheters avoids blind peritoneal instrumentation and is an effective method for minimizing potentially catastrophic vascular injuries.

Effect of Adipose-Derived Stem Cells on Head and Neck Squamous Cell Carcinoma

Objective Patients with head and neck squamous cell carcinoma (HNSCC) have significant wound-healing difficulties. While adipose-derived stem cells (ASCs) facilitate wound healing, ASCs may accelerate recurrence when applied to a cancer field. This study evaluates the impact of ASCs on HNSCC cell lines in vitro and in vivo. Study Design In vitro experiments using HNSCC cell lines and in vivo mouse experiments. Setting Basic science laboratory. Subjects and Methods Impact of ASCs on in vitro proliferation, survival, and migration was assessed using 8 HNSCC cell lines. One cell line was used in a mouse orthotopic xenograft model to evaluate in vivo tumor growth in the presence and absence of ASCs. Results Addition of ASCs did not increase the number of HNSCC cells. In clonogenic assays to assess cell survival, addition of ASCs increased colony formation only in SCC9 cells (maximal effect 2.3-fold, P < .02) but not in other HNSCC cell lines. In scratch assays to assess migration, fluorescently tagged ASCs did not migrate appreciably and did not increase the rate of wound closure in HNSCC cell lines. Addition of ASCs to HNSCC xenografts did not increase tumor growth. Conclusion Using multiple in vitro and in vivo approaches, ASCs did not significantly stimulate HNSCC cell proliferation or migration and increased survival in only a single cell line. These findings preliminarily suggest that the use of ASCs may be safe in the setting of HNSCC but that further investigation on the therapeutic use of ASCs in the setting of HNSCC is needed.

Open Reduction Internal Fixation for Midline Mandibulotomy: Lag Screws vs Plates

IMPORTANCE Midline mandibulotomy is a common approach for resection of head and neck oral cavity and oropharyngeal tumors; however, there are limited data available on the outcomes of lag screw vs plate fixation. OBJECTIVE To compare outcomes for midline mandibulotomy open reduction and internal fixation using plates vs lag screw technique. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study at a tertiary care academic medical center of patients undergoing midline mandibulotomy for head and neck tumor resection over a 6-year period. INTERVENTIONS Mandibular fixation using lag screws or plates. MAIN OUTCOMES AND MEASURES The medical records and computed tomographic (CT) scans of patients undergoing midline mandibulotomy for head and neck tumor resection over a 6-year period were retrospectively reviewed. The postoperative CT scans were reviewed by a neuroradiologist who graded the fusion site on a scale of 0 to 2 using a 2-pass method. The rates and grades of union were compared, as well as several factors that affect healing, for fixations performed with plates vs lag screws. RESULTS Thirty-seven patients were included. The overall rate of radiologic union was 90% (9 out of 10) for lag screw technique and 41% (11 out of 27) for plates (P = .01). The average grade of radiologic union was 1.3 for lag screws and 0.67 for plates (P = .04). Hardware exposure occurred in 4 (15%) of the plate group and fistulae formed in 3 (11%); neither complication occurred in the lag screw group. In univariate analysis, both presence of dentition (odds ratio [OR], 5.50 [95% CI, 1.33-22.73]; P = .02) and plate technique (OR, 13.09 [95% CI, 1.45-11.62]; P = .02) were significantly associated with nonunion. In multivariate analysis, plate technique had an OR of 8.32 (95% CI, 0.85-81.75) for nonunion (P = .07). CONCLUSIONS AND RELEVANCE Fixation of midline mandibulotomy with lag screws results in a significantly increased rate of radiologic union compared with plates. Lag screws were also significantly better at achieving radiologic union in patients who underwent postoperative radiation, and the rates of fistula formation and hardware exposure were lower. Thus, lag screw fixation of midline mandibulotomy should be considered an excellent option, especially when patients will undergo postoperative adjuvant therapy and in patients at high risk for wound complications.

Preoperative vitamin D level as predictor of post-thyroidectomy hypocalcemia in patients sustaining transient parathyroid injury

Several studies have sought to identify predictors of postoperative hypocalcemia after total thyroidectomy; however, there have been conflicting results regarding the impact of preoperative vitamin D deficiency.

Neck Mass With Progressive Shortness of Breath

Awoman in her 40s presented with progressive dyspnea and inability to lie flat. Two years prior to presentation, she had noticed a tender, firm thyroidenlargementassociatedwith rapidweightgain. She was hypothyroid with a thyroid-stimulating hormone level of 15.42mIU/Landa free thyroxine levelof0.95ng/dL. (Toconvert free thyroxine topicomolesper liter,multiplyby 12.871.) Shewas started on treatmentwith levothyroxine. Thyroid fine-needle aspiration revealedfibrosisandmixed inflammatorycells,andexaminationofcore biopsy specimen showed sclerosis and chronic inflammation. She was followed closely by an endocrinologist and treated with maximal medical therapy over 2 years without improvement. Computed tomographywithout contrast at the timeofpresentationdemonstrated trachealnarrowing to 1.56mm(Figure, A). Tracheostomywas recommendedwith the possibility of subtotal thyroid resectionpendingfeasibilityduringsurgery. Intraoperatively, the thyroid glandwas fibrotic and scarred to the anterior tracheal wall, sternothyroid, prevertebral fascia, and jugular vein. The recurrent laryngeal nerve (RLN)was encased in firm, fibrotic tissue requiring extensive dissection and reflection of the gland frommedial to lateral over the nerve. Total right thyroid lobectomywas successfully performedwithRLNpreservation, resulting in immediate improvement in airway caliber. Tracheostomy was not performed. Flexible laryngoscopy demonstrated normal vocal cord function at the first postoperativevisit, and thepatient’s dyspneaand inability to lay supine had completely resolved. Grossly, thespecimenwas tan, firm,and fibrotic.Theentire lobe appeared tobe involved in thediseaseprocess.Histopathologic examination revealed obliterative fibrosis and chronic inflammation (Figure,B). Immunohistochemical stains for total IgGand IgG4demonstrated increased IgG4-positive plasma cells (Figure, C). In addition, entrapped benign parathyroid tissue was noted (Figure, D). What is your diagnosis? A B