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Author(s): Carolyne Lallawmzuali [1]; Adil Aziz Khan [1]; Sana Ahuja [1]; Sufian Zaheer (corresponding author) [1] INTRODUCTION Adrenal cortico-medullary mixed tumors (CMMTs) are rare tumors, comprising of adrenal cortical and [...], Synchronous tumors comprising of cortical as well as medullary differentiation are rare in the adrenal gland. Collision tumors comprise of two independent neoplasms arising from the cortex and the medulla without any histological admixture. Adrenal cortico-medullary mixed tumors are rare tumors comprising of adrenal cortical and chromaffin cells intermixed with each other. Ganglioneuroma is a rare benign tumor originating from the paravertebral sympathetic ganglia and is rarely seen in the adrenal medulla. The presence of a synchronous ganglioneuroma with an adrenal cortical adenoma in the ipsilateral adrenal gland is exceedingly rare. We report a collision tumor comprising of an adrenal cortical adenoma and a ganglioneuroma detected as an incidental finding in a pediatric patient who presented with hypertension and palpitations.

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Background : To study the outcome of endoscopic third ventriculostomy (ETV) Methods: In this observational study an endoscopic third ventriculostomy was applied in patients who suffered from hydrocephaly. The diagnosis of hydrocephalus was determined by physical, neurological and neuro-radiological criteria. Patients with obstructed hydrocephalus whether congenital or acquired, with a dilated 3rd ventricle were included. Linear incision was given 2cm anterior to the coronal suture in mid pupillary line. Right frontal burr hole is made. For ETV, burr hole is placed on a line joining the foramen of monro and inter-peduncular line. Floor of the third ventricle was punctured close to or over the dorsum sellae. Membrane was dilated with balloon. Balloon was inflated and subsequently was taken out from puncture site. It ensured easy visibility of basilar artery and its perforators. Result: Age of patients ranged from 06 months to 24 years, with a mean age of 4 years . Fourteen patients had posterior fossa tumour's with dilated third ventricle, sixty four patients had aqua ductal stenosis, two patients with CSF ascites as complication of ventriculo-peritoneal shunt, eleven patients had blocked lower end of ventriculoperitoneal shunt. Seven patients had CSF leak. Time taken to complete endoscopic third ventriculostomy was from 20 to 40 min as compared to 1 hour to 1.30 hours, taken in a VP shunt. Patients who had ETV performed had a mean hospital stay of 3 days, where as patients in whom a VP shunt was performed stayed in the ward for an average of 5 to 10 days, depending on how eventful the post op period was. The cost incurred to the VP shunt patient who remained admitted for an average of 5 days was between Rupees 16,000 to 25,000, as compared to Rs: 2000 for the patient who underwent endoscopic third ventriculostomy. Conclusion: Patients of ETV, with less per operative time, had decreased length of stay. ETV also was less expensive to the patient and he did not have to buy the shunt apparatus with less rehospitalization rates, compared to patients who had undergone shunt. [ABSTRACT FROM AUTHOR]

Background: To determine the impact of time taken on the surgical outcome of extradural hematoma in patients with road traffic accidents. Methods: Sixty adult patients with history of road traffic accident with extradural hematoma on axial images of CT scan brain were included. All patients were allocated into three groups with 20 patients in each group. Patients in Group I were those in whom time from the occurrence of trauma to the surgical evacuation of hematoma was < 1 hour, 1 to 6 hours in group II and > 6 hours in group III. Results: In group I, majority (90 %) showed favourable outcome. In group II, 70 % showed favourable outcome. In group III, 50 % showed favourable outcome. Significant association was found between outcome and time of surgery (p<0.05). Conclusions: Frequency of favourable outcome after surgical evacuation was significantly higher in patients in whom surgery was performed within one hour after the trauma (P<0.05). [ABSTRACT FROM AUTHOR]

The article presents a case study of a 16 year old male with symptoms of posterior cervical region's painful swelling, and associated with fever, vomiting and odynophagia. It notes the diagnosis of Ewing's Sarcoma (EWS), which is a part of Ewing sarcoma family of tumours (ESFT), and small and round cell sarcoma is malignant neoplasm.

The article presents a case study of a 57-year-old-woman with headache, vomiting, altered conscious level for past 2 months. Topics discussed include brain magnetic resonance imaging (MRI) scan showed a well circumscribed lesion in the right frontal lobe with extension into the frontal sinus; mentions histopathology showed meningothelial meningioma; and also mentions radiation therapy has been associated with low rate of recurrence and in certain meningiomas improvement in patient's survival.

Background: To determine the success and effectiveness of non operative measures in patients with tuberculosis of the spine presenting with or without neurological deficit thus avoiding the surgical intervention. Methods : Seventy (M=20, F=50) patients were included and the study duration was 02 years. Selected patients were advised strict bed rest and antituberculous therapy (ATT) for 18 months. Surgery was done in those patients who presented with severe neurological deficits or non operative measures did not produce any improvement. Results : Pain was the most common presenting symptom (90%). Motor deficit was seen in 60% and incontinence in 10%. On investigations, end plate erosion was seen in 70% ,disc and body involvement in 30% ,paravertebral abscess in 40 % . Majority of the patients (70%) patients were treated successfully with non operative measures . Conclusion: Results are satisfactory in patients who are advised strict bed rest and ATT for 18 months. This helps in reducing the rate of surgical intervention in patients with spinal tuberculosis. It signifies the importance of ATT as it is the mainstay of treatment in spinal tuberculosis. [ABSTRACT FROM AUTHOR]

Background: To determine the effectiveness and safety of intermittent self catheterization in cauda equina patients who have lost the bladder control. Methods : In this prospective study patients with symptoms and signs of cauda equina syndrome, due to lumbar disc herniation confirmed by relevant MRI ,were included. Emergency surgery was performed and post operatively these patients were taught the technique of intermittent self catheterization. After full aseptic measures patients were asked to sit on the chair and identify the meatus. Catheter was slowly inserted into the bladder,uptil the urine output was obtained. Pressure on the lower abdomen was applied to help in emptying the bladder. Nelton catheter was removed and was kept in a bottle of clean water. After couple of attempts patients learnt to pass the catheter. Patient was asked and helped to do this activity 3 to 4 times a day. The patient was discharged from the hospital only when he/she was confident enough to catheterize himself/herself. Initially patients were kept on biweekly follow up and later on monthly basis. Results : Majority (86%) continued to undergo intermittent self catheterization, but 14% , elderly patients, experienced insertion difficulty and discontinued intermittent self catheterization. Ten patients (24%) had bacteriuria during the procedure. Epididymitis was seen in 2%. There were no urethral complications suggesting that the self-lubricating Nelton catheters are safe and less traumatic. Conclusion: Intermittent self catheterization is a safe, effective treatment and is associated with improved quality of life in cauda equina syndrome patients. [ABSTRACT FROM AUTHOR]

Purpose: Breast cancer subtypes are delineated by human epidermal growth factor receptor 2 (HER2) expression, pivotal in treatment selection. HER2-positive tumors typically respond to targeted therapies, whereas HER2-negative tumors lack HER2 overexpression. However, a subset exhibits low HER2 expression without amplification, termed HER2 low breast cancer. Despite being distinct, its clinicopathological characteristics and therapeutic implications remain less understood., Methods: A retrospective cohort study was conducted on histologically confirmed breast cancer cases from January 2022 to December 2023. Clinicopathological data including age, tumor size, nodal involvement, and hormone receptor status were collected. Immunohistochemistry categorized tumors into luminal, triple-negative, and HER2-enriched subtypes. HER2 expression was re-evaluated, classifying tumors into HER2 low and HER2-negative based on staining intensity and amplification status. Statistical analysis was performed using SPSS software., Results: Seventy female patients with breast cancer were included, exhibiting diverse clinicopathological features. HER2 low tumors (40%) were significantly associated with higher tumor stage (P=0.03), nodal involvement (P=0.01), and positive androgen receptor expression (P=0.01). Subgroup analysis revealed HER2 low hormone receptor-positive cases (78.6%) were associated with higher tumor stage (P=0.01) and nodal involvement (P=0.01), while HER2 low triple-negative cases (21.4%) demonstrated distinct characteristics such as higher histological grade (P=0.02)., Conclusion: This study underscores the complexity of HER2 low breast cancer and its implications for clinical management, emphasizing the need for personalized treatment strategies. It provides insights into the clinicopathological parameters of HER2 low breast cancers, highlighting their diverse characteristics and clinical implications.

Purpose: Gallbladder carcinoma (GBC) poses significant challenges in oncology due to its aggressive nature and limited treatment options. The lack of effective biomarkers for early detection and prognosis exacerbates the prognosis for GBC patients. Tumor budding (TB) and tumor infiltrating lymphocytes (TILs) have emerged as potential prognostic indicators in various cancers, reflecting tumor-host immune interactions and tumor aggressiveness. The study of TB and TILs in GBC is particularly important due to the limited literature available., Methods: This retrospective observational study aimed to evaluate the association of TB and TILs with clinicopathological parameters in GBC patients. Clinicopathological data were collected from patients with histologically confirmed GBC who underwent surgical resection. The sections were evaluated for TB and TILs using standardized methods. Statistical analysis was performed to assess associations between these parameters and clinicopathological variables., Results: Tumor stage and grade showed significant associations with TB and TILs, indicating their potential as prognostic markers. High TB correlated with advanced tumor stage and higher grade, while high TIL infiltration was associated with early tumor stage and lower grade. Additionally, TILs exhibited a significant association with lymphovascular invasion. Interestingly, an inverse association was observed between TB and TILs, highlighting the dynamic interplay between tumor aggressiveness and host immune response., Conclusion: TB and TILs hold prognostic significance in GBC, offering insights into its pathogenesis and potential therapeutic targets. Future research exploring the mechanistic underpinnings of tumor-host immune interactions in GBC is crucial for translating these findings into clinical applications and improving outcomes for patients.

Spinal cord injury without any radiographic abnormality (SCIWORA) is rare in adults. We describe here two case reports of adult patients, who presented to us with quadriplegia, following a road traffic accident. Plain radiography and computed tomography (CT) of cervical spine were normal. Hence the patients were diagnosed as cases of adult SCIWORA. However, subsequent magnetic resonance imaging (MRI) of the two patients revealed cervical cord injury in the form of cord contusion and disc protrusion, respectively. Patient with cord contusion was managed medically, whereas the patient with disc lesion was treated with discectomy. Patient treated with discectomy showed marked improvement. Therefore, patients having no osseous injury on X ray and CT scan should have an MRI study done to look for surgically correctable pathology. As in such rare patients of SCIOWRA an early diagnosis and timely intervention is crucial; with MRI playing a pivotal role.

Background: Ventriculoperitoneal (VP) shunt has been widely utilized in the treatment of hydrocephalus as a safe option but there is recent literature evidence that ventricularatrial (VA) shunt is not as notorious for its complications as proclaimed, to analyse and report our success with this procedure we conducted our study., Methods: A total of 64 patients undergoing VA shunting were included in this case series study conducted at RMC and Allied hospital Rawalpindi. The data was collected over a period of 4 years from, 1st June 2010 to 1st June 2015., Result: Our study included 64 patients who underwent a VA shunt for hydrocephalus. Their age ranged from 25 to 75 years. Most of the patients were females (60%). The following complications were observed with 2 (3.12%) patients having blockage of the shunt at the neck, 3 (4.68%) suffered from glomerulonephritis, 2 (3.1%) had post-operative neck hematoma, 4 (6.25%) had wound infection, short lower end of the tube was found in 3 (4.68%), migrated lower end (into the subclavian) was seen in 1 (1.56%). Mortality was 1 (1.56%). These results were comparable to other studies., Conclusion: Neurosurgeons have been doing a VA shunt as a second procedure, after a VP shunt when the need due to a complication was encountered. We however share our experience regarding ventriculo-atrial shunting, as first choice procedure, because of its low incidence of shunt blockage unlike VP shunt, which has high rate of shunt blockage and therefore warrants repeated surgeries.

Significant proportion of sellar masses is seen in clinical practice. They range from most common pituitary adenomas to rare inflammatory lesions. Presentation can vary and depends if it secretes any hormone or imparts a pressure effect upon the surrounding vital structures. Radiological imaging coupled with histopathology is important tools of diagnosis. Management options depend upon type of disease.

Background: Electrolyte derangements are common sequel of traumatic brain injury. Use of intravenous fluids, diuretics, syndrome of inappropriate ADH secretion and cerebral salt washing are some of the factors responsible for this. Proper in time detection followed by appropriate treatment not only improves neurological status but also decrease morbidity and mortality. This study was conducted to know serum derangements of different electrolytes in patients with traumatic brain injury., Methodology: This cross-sectional study was conducted in Pakistan Institute of Medical Sciences. Islamabad, Pakistan from Feb 2009 to Feb 2010. All adult patients with traumatic brain injury who presented to Neurosurgical department with severe head injury (GCS < 8) and who need monitoring in high dependency unit, were included in this study. Initially twice daily serum electrolyte monitoring for one week then once daily for remaining period of hospital stay was carried out. All samples were sent to Pathology department of Pakistan Institute of Medical Sciences, Islamabad. Patients who need corrective measures for imbalance had repetition of sampling after giving appropriate therapy. Statistical analysis was performed on SPSS-16., Results: Total 215 patients presented with severe head injury that were managed in high dependency unit. Out of which 127 (59.1%) were male and 88 (40.9%) were females. Most of them were adults between 21-40) years of age (21.4%; 24.7%). Sodium was the main electrolyte that underwent change & out of which hyper-natremia was major abnormality that occurred in 140 (65.1%) of patients. This is followed by hypo-kalemia that occurred in 79 (36.7%) of patients. Serum calcium & magnesium levels show little derangements., Conclusion: Electrolyte imbalance following traumatic head injury is an important cause to look for in patient monitoring. Sodium is the chief electrolytes of concern. Serum potassium and calcium levels also under goes notable changes.