Manjul Tripathi

Isolated tumorous Langerhans cell histiocytosis of the brainstem: a diagnostic and therapeutic challenge

Langerhans cell histiocytosis (LCH) of the CNS is a rare entity, known to involve primarily the hypothalamicpituitary region, with the clinical hallmark of diabetes insipidus. There have been a few reports of CNS LCH involving the brainstem as intraparenchymal enhancing lesions, but this has never been the presenting complaint of LCH. The authors report on a 7-year-old boy who presented with right cerebellopontine syndrome, in whom a well-defined, solid, enhancing lesion in the brainstem was diagnosed. Clinicoradiological differential diagnosis included glioma and tuberculosis. Biopsy revealed atypical histiocytes positive for CD68, CD1a, and S100 protein; these are the diagnostic features of LCH on histopathological examination. The rapid growth of the lesion was controlled with a chemotherapeutic regimen of cladribine.

M5 segment aneurysm presenting as "pure acute SDH"

Spontaneous “pure acute subdural hematoma (SDH)” is arguably a rare condition. We report on a pregnant female patient presenting as spontaneous acute SDH without subarachnoid hemorrhage (SAH) due to rupture of distal (M5 segment) middle cerebral artery aneurysm. We hereby discuss the diagnostic dilemma of this rare condition, along with the need for watchful evaluation of acute SDH without preceding head injury presenting in emergency outpatient departments, especially when it is first encountered by a trainee resident.

Atlanto-axial instability in achondroplastic dwarfs: a report of two cases and literature review.

Background: Achondroplasia is the commonest form of human dwarfism. The authors report atlanto-axial instability, in consequence to os odontoideum in this subgroup of patients. Methods: Two achondroplastic dwarfs harboring atlanto-axial dislocation are described along with radiological findings. Results: Both children underwent successful internal rigid immobilization, using sublaminar atlanto-axial wiring. Conclusions: Craniovertebral junction instability should be evaluated among these children, whenever foramen magnum insufficiency is being considered.

Pushing the limits of the Leksell stereotactic frame for spinal lesions up to C3: fixation at the maxilla

BackgroundSpinal radiosurgery is not considered in the domain of traditional Gamma Knife radiosurgery (GKRS) setup. The major obstacles in GKRS for upper cervical spine lesions remain in difficulty of frame fixation, avoiding collision and maintaining the integrity of the relative position of the lesion from image acquisition to treatment.MethodologyThe supraorbital margin remains the standard lowest fixation point for Leksell stereotactic frame. We describe fixation at the maxilla to target and treat upper cervical spine lesions (up to C3 vertebra) with measures to ensure cervical immobilisation and precision of the GKRS treatment.ResultsWe have treated two patients at the upper cervical spine up to C3 vertebra by fixing anterior pillars of the Leksell stereotactic frame at the maxilla. To ensure cervical immobilisation and precision of treatment, the neck was immobilised with a Philadelphia collar. The relative position between the head and sternum with the couch from image acquisition to the radiation delivery was kept constant. Docking angle was kept neutral (90 degrees) throughout the treatment (from image acquisition to actual treatment).ConclusionsThe maxilla is a potential alternative for stereotactic frame fixation. Measures to ensure cervical immobilisation with lower-down frame position permits treatment of lesions as low as C3 vertebra.

Prospective comparison of simple suturing and elevation debridement in compound depressed fractures with no significant mass effect

BackgroundCompound depressed fractures have conventionally been managed surgically with elevation and debridement to avoid infection, especially when there is dural penetration, nonetheless with little evidence. This study was to prospectively compare outcomes after simple suturing and elevation debridement in patients with compound depressed fractures.MethodsPatients of compound depressed fracture with GCS of five or more, no serious systemic injury, and no significant mass effect were prospectively studied for various factors in relation to infection, hospital stay, survival, and late post-traumatic seizures. Univariate and multivariate analyses were performed using SPSS21.ResultsOf the total 232 patients with complete clinico-radiological and follow-up data, 183 underwent simple cleansing and suturing, and 49 underwent surgical elevation debridement. The surgical group at baseline had significantly lower GCS, greater dural violation, and brain matter herniation compared to the conservative arm. Univariate analysis showed simple suturing group to have significantly shorter hospital stay (2.4 vs. 10.3xa0days) (pu2009<u20090.001), lesser infection among survivors (4 vs. 21xa0%) (pu2009=u20090.001), and greater ‘survival with no infection’ (85 vs. 69xa0%) (pu2009=u20090.01). Multivariate analysis adjusting for age, sex, GCS, dural penetration, and surgical intervention confirmed significantly shorter hospital stay (pu2009<u20090.001) and lesser infection among survivors (pu2009=u20090.02) in the simple suturing group. Overall, there was no benefit offered by surgical debridement. Simple suturing had a better outcome in most subgroups, except in those with brain matter herniation and GCS 5–8, which showed non-significant benefit with surgical intervention.ConclusionsSimple suturing seems to be an equally good option in patients with compound depressed fracture with no significant mass effect or brain matter herniation.

Middle ear rhabdomyosarcoma infiltrating the petrous with diffuse leptomeningeal spread in a child.

We present a case of middle ear rhabdomyosarcoma with intracranial erosion and later presented with diffuse leptomeningeal spread. Such lesions are difficult to eradicate and have a poor prognosis

Dose fractionated gamma knife radiosurgery for large arteriovenous malformations on daily or alternate day schedule outside the linear quadratic model: Proof of concept and early results. A substitute to volume fractionation

Background: To evaluate the feasibility, safety and efficacy of dose fractionated gamma knife radiosurgery (DFGKRS) on a daily schedule beyond the linear quadratic (LQ) model, for large volume arteriovenous malformations (AVMs). Material and Methods: Between 2012-16, 14 patients of large AVMs (median volume 26.5 cc) unsuitable for surgery or embolization were treated in 2-3 of DFGKRS sessions. The Leksell G frame was kept in situ during the whole procedure. 86% (n = 12) patients had radiologic evidence of bleed, and 43% (n = 6) had presented with a history of seizures. 57% (n = 8) patients received a daily treatment for 3 days and 43% (n = 6) were on an alternate day (2 fractions) regimen. The marginal dose was split into 2 or 3 fractions of the ideal prescription dose of a single fraction of 23-25 Gy. Results: The median follow up period was 35.6 months (8-57 months). In the three-fraction scheme, the marginal dose ranged from 8.9-11.5 Gy, while in the two-fraction scheme, the marginal dose ranged from 11.3-15 Gy at 50% per fraction. Headache (43%, n = 6) was the most common early postoperative complication, which was controlled with short course steroids. Follow up evaluation of at least three years was achieved in seven patients, who have shown complete nidus obliteration in 43% patients while the obliteration has been in the range of 50-99% in rest of the patients. Overall, there was a 67.8% reduction in the AVM volume at 3 years. Nidus obliteration at 3 years showed a significant rank order correlation with the cumulative prescription dose (p 0.95, P value 0.01), with attainment of near-total (more than 95%) obliteration rates beyond 29 Gy of the cumulative prescription dose. No patient receiving a cumulative prescription dose of less than 31 Gy had any severe adverse reaction. In co-variate adjusted ordinal regression, only the cumulative prescription dose had a significant correlation with common terminology criteria for adverse events (CTCAE) severity (P value 0.04), independent of age, AVM volume, number of fractions and volume of brain receiving atleast 8 Gy of radiation. Conclusion: DFGKRS is feasible for large AVMs with a fair nidus obliteration rate and acceptable toxicity. Cumulative prescription dose seems to be the most significant independent predictor for outcome following DFGKRS with 29-30 Gy resulting in a fair nidus obliteration with least adverse events.

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.

Safety and efficacy of single-fraction gamma knife radiosurgery for benign confined cavernous sinus tumors: our experience and literature review

Gamma knife radiosurgery (GKRS) has emerged as a suitable primary treatment option for confined cavernous sinus tumors (CSTs) and residual/recurrent benign tumors extending from the surrounding neighborhood. The aim of this review was to further investigate the safety and efficacy of single-fraction GKRS for primary confined CSTs (hemangioma, meningioma, and schwannoma). This was a retrospective analysis of 16 patients of CSTs, primarily treated with GKRS between 2009 and 2017. The patients underwent follow-up clinical and radiological evaluation at a regular interval. Data on clinical and imaging parameters were analyzed. The published literature on GKRS for CSTs was reviewed. There were total 16 patients (eight meningiomas, seven hemangiomas, and one schwannoma). Patients presented with a headache (56.3%), ptosis (50%), and/or restricted extraocular movements (50%). There was 46.6% tumor volume (TV) reduction after single-fraction GKRS. Hemangiomas showed best TV reduction (64% reduction at >u20093-year follow-up) followed by schwannoma (41.5%) and meningioma (25.4%). 56.3% of patients developed transient hypoesthesia in trigeminal nerve distribution. 44.4% of patients became completely pain-free. Among cranial nerves, the superior division of the oculomotor nerve showed best outcome (ptosis 62.5%) followed by an improved range of EOM. There was no adverse event in the form of new-onset deficit, vascular complication, or malignant transformation except for one out of the field failures. Among available treatment options, GKRS is the most suitable option by virtue of its minimally invasive nature, optimal long-term tumor control, improvement in cranial neuropathies, cost-effectiveness, favorable risk-benefit ratio, and minimal long-term complications.

Becoming Dr. Q: My journey from migrant farm worker to brain surgeon

When Dr. Q was a young boy living in a small village near Mexicali, he lost his baby sister, Maricela. He admired Kaliman, a comic book superhero, as a young child. He was from a poor family. However, when he was five, he worked at his dad’s gas station. He pumped gas, fixed cars and trucks, and even drove them. He also worked in Palaco’s cotton field and felt no shame in being a field worker. He believed that no job was meaningless.