R. Bhatia

Cranio-cerebral erosion (growing fracture of the skull in children). Part II. Clinical and radiological observations.

SummaryThis paper is based on a study of sixty cases of cranio-cerebral erosion treated in the Department of Neurosurgery. All India Institute of Medical Sciences, New Delhi during the last 20 years. This constitutes the largest series, so far reported from anywhere. It has provided a unique opportunity to get a comprehensive picture of the clinical and radiological features of this lesion, as also their evolution. These have been correlated with the findings at surgery and histopathological observations. The study highlights the incidence, pattern and severity of the brain damage associated with this lesion. Evidence has been provided for the progressive nature of the brain damage, not adequately emphasized in the existing literature. Pathogenesis of this brain damage has been discussed. The role of surgery in the management of this lesion has been outlined. Emphasis on the osseous changes or the “leptomeningeal cyst” (not really a consistent or important feature) in most publications on this subject has tended to minimize the significance of the brain damage in this condition. The authors suggest that the latter is far more important and therefore, recommend the use of nomenclature which takes this into account.

Medullomyoblastoma : a teratoma

Three cases of medullomyoblastoma in children are reported. The second case is unique in that in addition to areas of medulloblastoma and rhabdomyosarcoma, there were areas of well‐differentiated teratoma containing all mature elements. This observation lends support to the teratomatous nature of medullomyoblastoma.

Giant lumbosacral nerve sheath tumors

Cauda equina nerve sheath tumors are usually small, well-encapsulated tumors. Sometimes they may attain very large proportions, cause extensive bony changes, and resemble ependymomas in the cauda equina. They may also infiltrate into adjacent soft tissue planes and retroperitoneal spaces and yet be histologically benign. An awareness of this entity ensures aggressive surgical removal at the time of exploration. Primary neuro-fibrosarcomas or malignant changes in primary nerve sheath tumors of the cauda equina are seen in patients with neurofibromatosis.

Predictive value of visual evoked potentials in unilateral optic nerve injury

Forty-five patients with posttraumatic unilateral blindness were prospectively analyzed. The computed tomography scan was normal in all and an optic canal fracture was recorded in only one patient. Visual evoked potentials were performed within 48 hours of initial evaluation and repeated within 7 to 10 days. Five patients had normal visual evoked potentials and 15 patients had abnormal responses. No visual evoked potentials were recorded in 25 patients. Five patients with normal visual evoked potentials had good visual recovery. Thirteen of the 15 patients with abnormal responses also showed significant visual improvement. This study showed that positive visual evoked potentials were reliable in predicting the visual outcome; 90% of the patients with positive visual evoked potentials had complete or partial visual recovery.

Immunologic and immunogenetic studies in rheumatic fever and rheumatic heart disease

In order to evaluate all the important limbs of the immune system in the same patient population with rheumatic fever (RF) and rheumatic heart disease (RHD) cellular and humoral immune parameters as well as the immunogenetic profile in 265 North Indian patients with RHD were evaluated. They were studied for class in HLA antigens and 165 of them were also evaluated for the class II (DR locus) antigen profile. Data obtained was compared with 400 and 134 healthy controls respectively of the same ethnicity. Humoral immune parameters (Serum immunoglobulins IgG, IgA; Serum complement fractions C3, C4, C3d; circulating immune complexes and B lymphocyte numbers) and cellular immune parameters (total leucocyte and lymphocyte counts; T lymphocyte sub-populations-CD4, CD8 counts; lymphocyte migration inhibition to an extracellular streptococcal antigen, streptolysin ’O’) were studied in 23 patients with RF, 21 patients with “inactive” RHD and 20 normal controls. Patients of RHD were noted to have an increased frequency of DR3 (P < 0.001; Relative risk = 2.3) and a decreased frequency of DR2 (P < 0.001; Relative risk = 0.3) as compared to the controls. Patients of RF had evidence of an altered regulatory T cell function (Increased CD4/CD8 ratio) and decreased cell mediated immunity to streptolysin ‘0’. An increased humoral immune response (increased B cell counts, elevated serum IgG, circulating immune complexes and C3d) was noted in patients of RF as well as “inactive” RHD. An integrated pathogenetic model with immune response associated antigens of the DR locus influencing selection of cardiac cross-reactive antigens by the antigen processing macrophages, an altered regulatory T cell function with decreased suppressor T cell activity leading to an abnormal immune response is proposed to explain the pathogenesis of RF.

Haemostatic abnormalities in brain tumours

SummaryThe coagulation profile of 25 patients with brain tumours was studied preoperatively, intraoperatively and postoperatively. Ten patients had abnormal coagulation status preoperatively. Surgical intervention led to either an alteration of preexisting abnormality or appearance of new coagulation abnormality. Disseminated intravascular coagulation and fibrinolysis occurred with equal frequency in patients with meningiomas and gliomas. The alterations as a result of surgery were transient and compensated rapidly.

Serial transcranial doppler study in meningitis

SummarySerieal transcranial doppler studies were carried out in 12 patients, who developed meningitis during their hospital stay. Blood flow velocities in large basal vessels of the anterior circle of Willis were correlated with CSF pleocytosis and CSF sugar values. Mean blood flow velocities were found to be directly proportional to the CSF white blood cell (WBC) count and were inversely proportional to the CSF sugar values.Blood flow velocities were higher when CSF WBC count was raised. With only one exception these velocities decreased progressively with a fall in the CSF WBC count. At the time of meningitis there occurred a reduction in CSF sugar values and the blood flow velocities were significantly higher. With increase in CSF sugar values there occurred a gradual fall in the blood flow velocities.

Tuberculous brain abscess

SummaryTwo cases of tuberculous brain abscesses which were similar to pyogenic abscesses on routine histology are presented. Appropriate staining and culture techniques are essential for diagnosis of these lesions. The possible pathogenesis of tuberculous abscess in the brain is suggested.

Spontaneous rupture of the third ventricle in obstructive hydrocephalus: a radiographic diagnosis.

SummaryTwo cases of posterior fossa tumours with spontaneous rupture of the third ventricle are presented. In the first case there was dramatic relief of symptoms of raised intracranial tension. Rupture of the supra-pineal recess was demonstrated by Conray ventriculography in both cases.

Bilateral decerebration in head-injury patients: An analysis of sixty-two cases

The factors that contributed to recovery were reviewed in 62 head-injured patients with bilateral decerebration. The most important prognostic variables were age, mode of accident, time interval since injury, results of initial neurological evaluations, and the type of intracranial mass lesion. A higher survival rate was recorded in patients less than 20 years of age, those involved in nonvehicular accidents, those admitted within 6 hours of the accident, and where the vestibuloocular reflexes were preserved. Patients with extradural hematomas and those with nonsurgical intracerebral mass lesions also had a relatively better prognosis. In no patient was elective ventilation, steroid, or megadose barbiturate therapy utilized. Twenty patients (32%) of the 62 survived, and 11 patients had a good functional recovery.