Vr Roopesh Kumar

Spinal aneurysms: clinicoradiological features and management paradigms

OBJECT Spinal aneurysms (SAs) are rare lesions. The clinicoradiological features and the exact degree of their association with comorbid conditions such as arteriovenous malformations (AVMs) and coarctation of the aorta have not been definitively described. The ideal management paradigm has not been established. The authors reviewed literature to determine the clinical patterns of presentation, management, and outcome of spinal aneurysms. METHODS A systematic review of literature was performed using 23 separate strings. A total of 10,190 papers were screened to identify 87 papers that met the inclusion criteria. A total of 123 SAs could be included for analysis. RESULTS The mean age of patients at presentation was 38 years; 10% of patients were aged less than 10 years and nearly 50% were greater than 38 years. Spinal aneurysms can be divided into 2 groups: those associated with AVMs (SA-AVMs, or Type 1 SAs) and those with isolated aneurysms (iSAs, or Type 2 SAs). Patients with Type 2 SAs were older and more likely to present with bleeding than those with Type 1 SAs. The acute syndromes can be divided into 3 groups of patients: those with spinal syndrome, those with cranial/craniospinal syndrome, and those with nonspecific presentation. Overall, 32.6% presented with angiography-negative cranial subarachnoid hemorrhage (SAH). Presentation with evidence of cord dysfunction (myelopathy/weakness/sensory loss/bladder involvement) correlated with poor outcome, as did presentation with hemorrhage and association with other comorbid conditions. Surgery and endovascular therapy both led to comparable rates of complete aneurysm obliteration for Type 2 SAs, whereas for the AVM-associated Type 1 SAs, surgery led to better rates of lesion obliteration. The authors propose a classification scheme for spinal aneurysms based on whether the lesion is solitary or is associated with a coexistent spinal AVM; this would also imply that the ideal therapy for the aneurysm would differ based on this association. CONCLUSIONS The clinical and radiological patterns that influence outcome are distinct for Type 1 and Type 2 SAs. The ideal treatment for Type 1 SAs appears to be excision, whereas surgery and endovascular therapy were equally effective for Type 2 SAs.

Vascular endothelial growth factor expression and angiogenesis in various grades and subtypes of meningioma.

BACKGROUND Vascular endothelial growth factor (VEGF) expression has been extensively studied in astrocytoma, whereas relatively less literature exists on VEGF expression in meningioma. MATERIALS AND METHODS Patients operated for meningioma from 2006 to 2011 (n = 46) were included. Tumor was subtyped and graded as per WHO grading. Immunohistochemistry was performed for MIB labeling index, VEGF, and CD 34 staining. The patterns of VEGF expression in various histological subtypes and grades and its correlation with microvascular density were analyzed. RESULTS This series consisted of 40 Grade I meningioma, 4 Grade II tumors, and 2 Grade III tumors. While 14 (30.4%) tumors showed no staining with VEGF antibody, 32 (69.6%) were positive for VEGF. Sixty five percent of Grade I tumors showed VEGF positivity, while 100% of Grade II and Grade III tumors were VEGF positive (P = 0.157). The mean microvascular density in VEGF-negative tumors was 9.00, while that of VEGF-positive tumors was 17.81(P = 0.013). There was a gradual increase in microvascular density from tumors which are negative for VEGF to tumors which expressed moderate to strong VEGF, the difference being statistically significant (P = 0.009). CONCLUSIONS VEGF expression correlated with the microvascular density in meningioma irrespective of tumor grade, with a gradual increase in microvascular density in relation to the VEGF score.

Supratentorial enterogenous cyst: a report of two cases and review of literature.

Enterogenous cyst is extremely rare in the supratentorial compartment. Two adult patients with histologically variefied supratentorial entrogenous cyst are described. Light microscopy and immunohistochemistry examination revealed the endodermal origin of the cyst. Enterogenous cyst should be considered in the differential diagnosis of non-enhancing cyst in the supratentorial compartment. Total excision of the cyst wall should be done wherever feasible. Preventing spillage of the cyst contents during surgery is mandatory to avoid postoperative intractable seizures and craniospinal dissemination.

Retinal nerve fiber layer thickness analysis in cases of papilledema using optical coherence tomography – A case control study

BACKGROUND Papilledema is defined as an optic disk swelling that is secondary to elevated intracranial pressure. Early diagnosis of papilledema can help in early intervention thus preventing visual loss and even death. Optical coherence tomography (OCT) is a non-invasive imaging technique which can detect and quantify diffuse thickening of the retinal nerve fiber layer (RNFL) in eyes with optic disk edema. AIMS To assess the difference in the RNFL thickness in patients with papilledema from controls using OCT and to correlate the RNFL thickness with the degree of papilledema. SETTING AND DESIGN A case control study was conducted from August 2011 to July 2013 in a tertiary care medical college of south India. METHODS AND MATERIALS All adult patients diagnosed or suspected to have papilledema were included in the study. Disk photographs were graded according to modified Frisen criteria. Fast RNFL protocol on time-domain OCT was used. Cases and controls were compared. STATISTICAL ANALYSIS RNFL thickness was compared using an independent samples t-test. Correlation between RNFL thickness and modified Frisen scale of papilledema was done using Spearman correlation. GraphPad InStat 3 version was used. RESULTS A total of 100 cases and 126 controls were studied. Statistically significant thickening of retinal nerve fiber layer (RNFL) was seen in all quadrants in patients with papilledema as compared to controls. A positive correlation was found between Frisen grading of papilledema RNFL thickness measurements. CONCLUSIONS RNFL thickening was mainly in the inferior and superior peripapillary region and was greater in higher grades of papilledema. A strong positive correlation was found between RNFL thickness and the Frisen scale for grading of papilledema. OCT can be included as a routine non-invasive quantitative tool for detection of early papilledema.

Larsen syndrome with C3-C4 spondyloptosis and atlantoaxial dislocation in an adult.

Study Design. This is a clinical case report with a review of relevant literature. Objective. To describe a case of Larsen syndrome with C3–C4 spondyloptosis and atlantoaxial dislocation in a middle-aged female patient and to discuss management strategies. Summary of Background Data. Spondyloptosis of the cervical spine is relatively rare and is caused by trauma, destruction of the vertebral bodies by tumors, or tuberculosis. Such gross vertebral displacement is usually associated with significant neurological deficits. Larsen syndrome is characterized by multiple joint displacements and can, very rarely, be associated with nontraumatic spondyloptosis of the cervical vertebra. A single case report of C1–C2 joint laxity causing atlantoaxial dislocation in a patient with Larsen syndrome is available in literature. No reports of any patient (with Larsen syndrome or nonsyndromic) who had both cervical spondyloptosis and atlantoaxial dislocation are available in literature. Methods. A 36-year-old female presented with chronic neck pain, bilateral hand deformity, and mild spasticity involving all 4 limbs. Cervical radiograph, computed tomographic scan, and magnetic resonance image revealed C3–C4 spondyloptosis and atlantoaxial dislocation. Results. A combined ventral decompression of subaxial spine and instrumentation from C2 to C5, followed by posterior C1–C2 distraction arthroplasty and lateral mass stabilization of the subaxial spine up to C6, was done. The cervical deformity was corrected, and the patient remains symptom free. Conclusion. Patients with spondyloptosis of the cervical spine can rarely present with chronic neck pain and minimal neurological deficits. An additional pathology, such as atlantoaxial dislocation, can add to the complexity. Circumferential stabilization and fusion would be required in such cases to achieve a good outcome. Larsen syndrome is a rare cause of nontraumatic cervical displacements.

Remote spinal epidural haematoma after spinal anaesthesia presenting with a 'spinal lucid interval'.

An obstetric patient who had no significant risk factors developed a spinal epidural haematoma remote from the site of needle puncture (for administration of spinal anaesthesia). The clinical deficits were manifest after recovery from the motor blockade had started a phenomenon that we have termed as a ‘spinal lucid interval’. The patient developed flaccid paraplegia with a sharp sensory level and urinary retention. The patient underwent emergency laminectomy and evacuation of the haematoma. She gradually recovered near normal power and was ambulant independently and had normal sphincter function at follow-up.

Giant cavernous carotid artery aneurysm mimicking a fungal granuloma and presenting with massive epistaxis

A 42-year-old man presented with frequent minor nasal bleeds since 1 month. He was undergoing chemotherapy for pulmonary tuberculosis. MRI brain revealed a space occupying lesion in the right cavernous sinus extending to sphenoid sinus, with T2 inversion. An initial diagnosis of fungal granuloma was made and endoscopic trans-nasal biopsy was attempted. During surgery, a pink pulsating mass was seen in the sphenoid sinus and the procedure was abandoned. A cerebral CT-angiography done subsequently revealed a giant right cavernous segment internal carotid artery (ICA) aneurysm. He was then referred to our centre and upon admission he collapsed secondary to a major bout of epistaxis. An emergency cervical carotid artery ligation resulted in transient control of epistaxis. Owing to recurrence of bleed, trapping of the aneurysm was done resulting in cure. The present case shows that a giant cavernous ICA aneurysm can occasionally be erroneously diagnosed as fungal granuloma.

An evaluation of the finger flexion, Hoffman's and plantar reflexes as markers of cervical spinal cord compression – A comparative clinical study

OBJECTIVES This study aimed at determining the frequency of abnormal finger flexion, Hoffmans and extensor plantar (Babinski) response in healthy adults and to determine the sensitivity and specificity of these tests as markers of spinal cord compression in symptomatic patients. METHODS Patients attending the neurosurgery clinic with neck related complaints formed the case group. The control group consisted of consenting patient attenders and volunteers drawn from the students and faculty of our institute. All subjects underwent examination of the finger flexion, Hoffmans and plantar reflexes and an MRI as per standard protocol. The frequency of the reflexes in the control group, sensitivity and specificity of the reflexes to detect cord compression in the case group were computed. RESULTS The frequency of the reflexes in healthy controls were finger flexion - 1%, Hoffmans - 0.3% and Babinski sign - 0%. None of the controls with positive reflexes had any abnormality on MR imaging. A combination of the three reflexes had a sensitivity of 91.7%, specificity of 87.5%, PPV of 95.7% and NPV of 77.8% in detecting spinal cord compression. CONCLUSIONS A combination of finger flexion, Hoffmans and plantar reflexes could be used effectively as a marker of spinal cord compression in symptomatic individuals. They cannot, however, be depended on as screening tests in asymptomatic individuals.

Cranial polyneuropathy associated with vertebrobasilar dolichoectasia

The patient was a 68-year-old man who had been diagnosed ith autosomal dominant polycystic kidney disease (ADPKD) four ears previously. He had hypertension secondary to renal disease. hree years previously, he had developed occasional episodes of ancinating pain on the left side of his face lasting a few seconds. he distribution was over the cheek and lower jaw (suggestive of 2 and V3 neuralgia). Gradually these episodes became more freuent and were precipitated by brushing teeth, chewing on the left ide of the mouth, exposure to cold air and drinking cold water. ain frequency and intensity had increased to the extent of interering with his eating habits and sleep pattern. He had consulted octors at a local hospital and had been on pain medication on and ff. One year after the onset of facial pain, he developed twitching f the left side of his face. These episodes initially occurred interittently but subsequently the twitching was constantly present.

Trans-ciliary minimally invasive keyhole craniotomy for skull base and vascular lesions

Sir, Conventional approaches to the anterior and lateral skull base would necessarily include a large craniotomy and possibly an orbitozygomatic osteotomy.[1,2] Approach-related complications include visible scars, increased blood loss during surgery, facial and orbital ecchymosis, and long-term problems such as temporalis muscle atrophy and painful jaw opening.[2] Many skull base lesions can be easily accessed via a minimally invasive keyhole craniotomy using an eyebrow incision. This approach is effective in minimizing surgical trauma, hospital stay, and long-term morbidity.[3,4]