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Hemorrhagic complications of acute leukemia are well described and are a common cause of mortality in these patients. However, to our knowledge, fatal intracerebral hemorrhage (ICH) as an initial presentation of acute lymphocytic leukemia (ALL) has only been reported once. We report a case of previously undiagnosed ALL presenting with ICH. Our patient is a 17-year old male who was found unresponsive several hours after complaining of headache. Initial emergency room evaluation found the patient to have anisocoria with a fixed and dilated right pupil and demonstrated evidence of decorticate posturing. Imaging revealed a large right-sided intraparenchymal hemorrhage, intraventricular hemorrhage, midline shift, and uncal herniation. Laboratory evaluation showed marked leukocytosis with blastic predominance and evidence of disseminated intravascular coagulopathy. Emergent surgical intervention was performed. However, despite evacuation of the hematoma, the patient eventually progressed to clinical brain death. Usually, ICH is seen in ALL patients after the diagnosis has been made. We report a unique case of fatal intracranial hemorrhage as the initial presentation of ALL and discuss the possible management dilemmas to treat such entities. ALL should be kept in the broad differential diagnosis of spontaneous ICH, especially in a young patient with evidence of severe coagulopathy.

Aim: Intracranial arachnoid cysts account for 1% of all intracranial mass lesions and may require drainage if symptomatic., Material and Methods: We retrospectively reviewed the medical records of 45 consecutive patients who underwent surgical drainage for symptomatic intracranial cysts at our institution from January 2000 to January 2010. The average age of our patients was 36.2 years; 26 were female and 19 were males. The most common symptoms included headaches (73.3%) and dizziness (35.6%)., Results: Cyst wall fenestration was carried out in 29 (64.4%), Cystoperitoneal shunting in 6 (13.3%) and endoscopic fenestration and stealth guided craniotomy in 5 patients each (11.1%). Seven patients had perioperative complications, and on discharge 79.1% of all patients had partial or complete clinical relief and 85.7% showed radiological decompression. A maximum cyst dimension of more than 5.0 cm was significantly associated with worse outcome at discharge (p=0.02). There was no association between post-operative size cyst decompression and resolution of clinical symptoms. The clinical and radiological outcomes were comparable between different surgical methods., Conclusion: There was no difference in the outcomes between different modalities. The extent of post-operative radiological reduction had no correlation with clinical outcomes, and should be assessed in relation to the patient's clinical status.

Postpartum cerebral angiopathy (PPCA) is a rare form of reversible cerebral vasoconstriction syndrome. A 39-year-old female presented with a 5×6 cm left frontal intracerebral hemorrhage (ICH) and following an emergent neurosurgical evacuation of ICH, she developed a contralateral ICH and intraventricular hemorrhage. Her postoperative course was highlighted by the finding of diffuse bilateral segmental vasospasm on angiography and trans-cranial Doppler, left anterior cerebral artery region infarct and intractable elevated intracranial pressure (ICP). Medical management including osmotic therapy, nimodipine, corticosteroids, and phenytoin was unable to control ICP. Intractable elevated ICP led to evacuation of the right-sided ICH. After 3.5 years, the patient appears to be cognitively intact but continues to have right lower extremity weakness and is wheelchair-bound. Our case suggests that PPCA can rarely manifest as a life-threatening emergency for which neurosurgical intervention may be life-saving.

Objectives: To assess the levels of stress in the face of terrorism and the adopted coping strategies, amongst the student population of universities in Karachi., Methods: A descriptive, cross sectional study was conducted on undergraduate students from four universities of Karachi. Self-administered questionnaires were filled out by 291 students. Pearson Chi-Square test was used to assess associations between stress levels and different variables at a level of significance of 0.05%., Results: A total of 65.8% of the students had mild stress levels, 91.5% of university students were exposed to terrorism through television, while only 26.5% students reported personal exposure to terrorism. 67.4% students were forbidden by their parents to go out (p = 0.002). Most of those who had self exposure to an attack were the ones whose parents forbade them from going out (p = 0.00). Most commonly used coping strategy was increased faith in religion. Irritability was the most common stress symptom., Conclusion: A majority of students studying in universities of Karachi had mild stress levels due to the constant threat of terrorism whereas a minority had severe stress levels. Possible reasons for resilience and only mild stress levels could be the history of Karachi's internal conflicts and its prolonged duration of being exposed to terrorism. These students who are positive for stress need to be targeted for counseling either through the media or through their universities. More extensive research is needed in this area.