Sumit Bansal

Cavernous sinus hemangioma: a fourteen year single institution experience.

Cavernous sinus hemangioma (CSH) is a rare extra-axial vascular neoplasm that accounts for 2% to 3% of all cavernous sinus tumors. Their location, propensity for profuse bleeding during surgery, and relationship to complex neurovascular structures are factors which present difficulty in excising these lesions. The authors describe their experience of 22 patients with CSH over 14 years at a tertiary care center. Patients were managed with microsurgical resection using a purely extradural transcavernous approach (13 patients) and with Gamma Knife radiosurgery (GKRS; Elekta AB, Stockholm, Sweden) (nine patients). Retrospective data analysis found headache and visual impairment were the most common presenting complaints, followed by facial hypesthesia and diplopia. All but one patient had complete tumor excision in the surgical series. Transient ophthalmoparesis (complete resolution in 6-8 weeks) was the most common surgical complication. In the GKRS group, marked tumor shrinkage (>50% tumor volume reduction) was achieved in two patients, slight shrinkage in five and no change in two patients, with symptom improvement in the majority of patients. To our knowledge, we describe one of the largest series of CSH managed at a single center. Although microsurgical resection using an extradural transcavernous approach is considered the treatment of choice in CSH and allows complete excision with minimal mortality and long-term morbidity, GKRS is an additional tool for treating residual symptomatic lesions or in patients with associated comorbidities making surgical resection unsuitable.

Ten years' experience in the management of spinal intramedullary tumors in a single institution.

We retrospectively reviewed the outcomes of 195 patients with intramedullary tumors who underwent surgery between January 2001 and December 2010 at a single institution. The symptomatology, neurological and neuroradiological findings, operative details, perioperative and postoperative complications, histopathological data and follow-up examinations of the 137 (70.2%) males and 58 (29.7%) females were studied and analyzed. Epidermoid was the most common intramedullary tumour in children (23%), whereas in adults, ependymomas were more common (46%). Ependymomas were more amenable to resection (total excision in 57.7% and near-total excision in 39.4%) as compared to astrocytomas (total excision in 29%; near total excision in 60.5%). At the final clinical follow-up, 24 patients (16.4%) had improved in McCormick grade, 112 patients (76.7%) remained unchanged and 11 patients (7.5%) had worsened. Complete removal of the lesion is the primary goal of surgery. We conclude that the strongest predictor of functional outcome was the preoperative neurological condition, beyond the histological differentiation of the intramedullary tumor.

Jugular foramen schwannomas: A single institution patient series

Jugular foramen schwannomas are rare. To our knowledge only a small number of series including a large number of patients have been reported. We aimed to analyse the clinical characteristics, surgical approaches, and outcome of patients undergoing treatment for jugular foramen schwannomas via a retrospective analysis of departmental records. Data for 28 patients treated for jugular foramen schwannomas in the Department of Neurosurgery at our tertiary level referral institution between January 2001 and December 2010 were analysed. Most patients were in the fourth decade of life, with the duration of symptoms ranging from 1 month to 13 years. A skull base approach was used in every surgically treated patient. Of the 19 patients for whom radiological follow-up were available, complete tumor excision was achieved in 17 patients. Follow-up ranged from 3 months to 59 months (mean, 32 months). One patient died and three had permanent morbidity in the form of facial nerve palsy. Jugular foramen schwannomas are best treated by total surgical resection. Partial resection is appropriate for tumors with adhesions to the brainstem and in medically unfit patients. Subsequent radiosurgery can be used for small residual tumors.

Factors affecting surgical outcome of endoscopic third ventriculostomy in congenital hydrocephalus

Endoscopic third ventriculostomy (ETV) is an accepted modality of treatment for obstructive hydrocephalus, with good results in adult patients. However in the pediatric age group results vary from poor to similar to the adult population. This study evaluates the outcome of ETV in congenital hydrocephalus of both early and delayed presentation, and investigates factors that determine the outcome. Patients with congenital hydrocephalus who underwent ETV between January 2006 and December 2011 were retrospectively analyzed. Any conditions potentially influencing the need for redo surgery (persistent cerebrospinal fluid [CSF] leak not responding to local measures, tense fontanelle, increased ventricular size, recurrence of symptoms or radiological evidence of failure) were analyzed. A total of 102 patients with a mean age of 7.45years were included. Presenting features were increasing head circumference and delayed milestones. Ninety-eight patients had triventricular hydrocephalus due to aqueductal stenosis. Procedures performed were ETV only (n=74), ETV with aqueductoplasty (n=22), ETV with cystoventriculostomy (n=2) and aqueductoplasty only (n=2). Failure of ETV occurred in 11 patients and all were managed with a ventriculoperitoneal shunt. CSF leak in the perioperative period was the only factor that was significantly associated with failure of ETV. ETV is a safe procedure with a good success rate and can be offered to children with aqueductal stenosis. There is a higher chance of failure if there is a CSF leak in the early or late postoperative period.

Management of hypoglossal schwannomas: single institutional experience of 14 cases.

Background Hypoglossal schwannomas are rare intracranial neoplasms. Microsurgical resection with the goal of cure is the aim of management but is associated with a high rate of postoperative morbidity. Objective The objective of the study was to outline the clinical presentation, radiologic characteristics, surgical techniques, postoperative morbidity, and long-term follow-up results for hypoglossal schwannomas. Methods Patients treated for hypoglossal schwannoma at the Department of Neurosurgery of a tertiary-level referral institution from January 2001 until December 2010 were analyzed retrospectively using hospital records. Results There were 14 patients who were treated in the study period. Tongue atrophy and swallowing difficulties were the most common presenting symptoms. Surgery done in 12 patients using a variety of approaches (retromastoid retrosigmoid suboccipital in 9, midline suboccipital in 2, and far lateral in 1). Five patients having small residual tumors received gamma knife (GK) subsequently. two patients received primary GK stereotactic radiosurgery. Three patients had permanent morbidity in the form of cranial nerve paresis. Immediate postoperative complications like cerebrospinal fluid leak and pneumonia were present in three patients. Conclusion Complete microsurgical resection is often associated with a high rate of morbidity. Subtotal and near-total resection followed by stereotactic radiosurgery or observation now offers an alternative approach.

Ganglioglioma: Single-institutional experience of 24 cases with review of literature

Background: Ganglioglioma is a common seizure associated tumor. The goal of this study was to observe the postoperative outcome in patients with gangliogliomas. Material and Methods: A total 24 patients with gangliogliomas who underwent surgery at our institute from 2008 to 2011 were included. There were 13 males (54%) in our study. A retrospective analysis for the demographic profile, surgery and outcome was performed using STATA software. Literature on this subject was also reviewed, MEDLINE and PUBMED databases were searched. Observations: Sixteen patients presented with signs and symptoms of raised intracranial pressure and 12 patients had seizure disorder. Average age at surgery was 20 years (range 7-50 years). Twelve each were located in the temporal lobe and extra-temporal location. Intra-operative electrocorticography (ECoG) alone in three and image guidance alone were used in two patients, respectively. Both ECoG and image guidance were used in one patient and none of them was used in 18 patients. Gross total resection was achieved in 17 patients. After a mean follow-up of 1.6 years (range 3 months to 2.5 years), out of 12 patients with preoperative seizures, 10 (83.3%) were seizure free (Engel class-I) and 2 (16.6%) belonged to Engel class-II. None of the factors, including age at surgery, seizure duration prior to surgery, type of seizures, use of intra-operative ECoG and image guidance, extent of tumor resection, and surgical strategy proved to have significant correlation with postoperative seizure outcome. Conclusions: Surgical treatment is effective and safe for patients with gangliogliomas. Neither intra-operative ECoG nor image guidance necessarily leads to better seizure control, although they are useful adjunct for achieving safe and complete tumor resection.

Role of anesthesiologist in ex utero intrapartum treatment procedure: A case and review of anesthetic management

The ex utero intrapartum treatment (EXIT) procedure is a rare form of perinatal resuscitation. It is basically a bridge therapy between partial delivery of the child and stabilization of its cardiorespiratory functions. This procedure has multiple anesthetic challenges including maternal anesthesia, maintenance of uteroplacental flow, tocolysis till the neonate is stabilized, management of postpartum hemorrhage, fetal, and neonatal anesthesia. This review also describes a case of cervical teratoma in fetus, for which the EXIT was performed in our institute. In addition to the case description, multiple concerns specific for EXIT procedure are discussed in this review.

Nondystrophic holocord intramedullary lipoma: an uncommon case

Dear Editor: Intramedullary lipomas are uncommon benign tumors accounting for less than 1% of all spinal cord tumors [1]. Spinal cord lipomas are frequently associated with dysraphism and occur in the thoracic spine. Nondysraphic spinal cord lipomas usually present in the second or third decade of life. Intramedullary lipomas are often focal, and only a few cases of extensive cervico-thoraco-lumbar intramedullary lipomas have been reported [1, 2]. Authors are reporting one such case. A 17-years old female patient presented with a history of progressive weakness of bilateral lower limbs for 6 months. Physical examination showed spastic paraplegia (MRC grade = 0/5) with brisk bilateral knee and ankle jerk with the bilateral ankle clonus. There was 90–95% sensory loss to touch and pain below the D4 dermatome, and she was continent. Magnetic resonance imaging (MRI) of the spine revealed a long segment (D2-D10) intramedullary mass with exophytic component along with intradural extramedullary lesions at D12 and L1 level (Fig. 1). They were hyperintense on both T1-weighted and T2weighted images. The fat saturated T1-weighted images showed a total signal suppression of these lesions confirming their lipomatous nature. There was no enhancement with gadolinium. There was no evidence of spinal dysraphism. Patient was taken up for surgery and D2-L1 laminotomy was done. The dura was opened from D2-L1. A diffuse cord bulge with overlying lipoma was seen throughout with proximal and distal intramedullary extension of the tumor at D2D10 level. The tumor was soft to firm, yellowish, mildly vascular with poor plane of cleavage from normal spinal parenchyma and exiting nerve roots. Near total excision of the tumor fromD2-D10 was done with part of the tumor attached to nerve roots. The spinal cord was lax and pusatile after tumor excision. Two intradural extramedullary lesions lipomas at the level of D12 and L1 were seen. Gross total excision of both tumors was done sparing exiting nerve roots. The lamina were replaced and fixed. Histopathological examination confirmed the diagnosis of the lipoma in all three tumors (Fig 2). Postoperatively, patient’s motor power remained same and active limb physiotherapy was continued. Symptoms often appear in the second and third decades with no significant gender predominance. The clinical manifestations include paraparesis, spasticity, gait difficulties, urinary incontinence, sensory disturbances, and localized pain. MRI is the modality of choice in diagnosing these lesions. It shows the lipomatous nature of the tumor associated with a homogenously hyperintense signal on T1-weighted images, a hyperintense signal in T2weighted images, and signal suppression on fat suppression sequences [2]. There are several theories on the developmental mechanism of spinal cord lipomas. Most theories contribute the development of dysraphic spinal cord lipomas to an adipocyte migration problem during embryological development [3]. Unfortunately, the pathogenesis of nondysraphic spinal cord lipomas is unclear. Surgical management of this rare pathology has a wide variety of options. Depending on the neurologic deficits, observation to gross total resection may be reasonable options. If severe neurologic deficits are observed, decompression with an attempt at resection may be the treatment of choice as done in our case. * Sumit Bansal drsumitbansal@gmail.com

Effect of selected yogic practices on pain and disability in patients with lumbar spondylitis

Aim: The study was designed to find the effect of selected yogic practices on lumbar spondylitis. Materials and Methods: This was a prospective, randomized study without a control trial. A total of 172 participants with lumbar spondylitis (age 21–79 years) from the outpatient department (OPD) of neurosurgery, AIIMS, Bhubaneswar, were randomly assigned to receive yoga therapy. The module of selected yogic practices consisted of pawanamuktasana series 1 (loosening and strengthening), asana, pranayama, and relaxation techniques Yoga Nidra. Statistics Analysis: Within groups, comparison was done by paired t-test, and between groups, ANOVA test was carried out to determine the significant difference among the various groups under study. Correlation regression analysis was done to measure the degree of linear relationship between pre- and post-study for various groups. Results: Significant differences were observed with yoga therapy in instant relieve practice group, in short-term practice group, and in long-term practice group (LTPG) with better results in LTPG. Conclusion: Selected yoga therapy has got the better result in management of pain in lumbar spondylitis.

Intraoperative wandering atrial pacemaker with isoflurane anaesthesia.

Sir, Wandering atrial pacemaker is an arrhythmia originating from the shifting pacemaker sites from the sinoatrial node to the atria and/or atrioventricular node and back to the sinoatrial node.[1] We report an incident of wandering atrial pacemaker occurring intraoperatively during surgery for testicular torsion. A 10-year-old boy, American Society of Anesthesiologists (ASA) physical status I, undergoing surgery for a right-sided testicular torsion had received fentanyl, propofol and atracurium for anaesthesia management. After securing his airway with a ProSeal™ laryngeal mask airway, anaesthesia was maintained with isoflurane, air and oxygen under standard ASA monitoring. During manipulation of the testis, he had an episode of bradycardia with heart rate decreasing from 88/min to 54/min without any hypotension or oxygen desaturation that persisted for about 15 s. This was followed by an arrhythmia with rate of 74–78/min having varyingP wave morphology and PR interval that resolved spontaneously [Figure 1 and Video 1]. We diagnosed it to be a case of wandering atrial pacemaker as the heart rate was between 60 and 100/min, with slight irregularity, beat to beat changing shape and size ofP wave of at least three different forms, varying PR interval but normally appearing QRS complexes.[2] The likely cause of occurrence of arrhythmia was vagal stimulation caused by testicular manipulation. All commonly used volatile anaesthetic agents including isoflurane are known to cause enhanced automaticity of subsidiary atrial pacemakers,[3] thereby predisposing to the development of atrial arrhythmias and wandering pacemaker phenomenon. Monitoring and recognising this event for possible haemodynamic compromise are important. Figure 1 Variant morphology of P wave in lead II