Unusual presentation of differentiated thyroid cancer metastasis

Introduction  The rates of thyroid cancers are on a rise, especially well-differentiated thyroid cancers. This could be partly due to newer diagnostic modalities, like high-resolution ultrasound, that can pick up smaller lesions. Differentiated thyroid cancers with distant metastases are not common, and even rarer is the initial presentation with complaints not related to the neck. Objectives  The objective of this series was to study and report the unusual cases of patients with differentiated thyroid cancer with distant metastasis. There is a lack of data in the literature on these cases, and due to the rarity of such metastases, no definite treatment protocol has been defined. Methods  A retrospective chart review of 1,200 cases of thyroid surgeries was performed. A total of 10 cases of well-differentiated thyroid cancer on the final histopathology exam that had initially presented with usual complaints to departments other than the Otolaryngology Department were identified. Results  A total of 6 patients had papillary carcinoma, whereas 4 patients had follicular carcinoma on final the histopathology exam. Two patients presented with iliac crest lesions, 2 with vertebral lesions one each with parapharyngeal mass, supraclavicular mass, labia majora swelling and bleeding, lung, rib and neck of femur lesion. Conclusion  There are still no specific guidelines on how to address these patients with differentiated thyroid cancer with distant metastasis (except for the cases of bone and lung lesions) and on which treatment should be offered in case of recurrence. More studies on the subject are required

Quality of life among patients undergoing decompressive craniectomy for traumatic brain injury using glasgow outcome scale extended and quality of life after brain injury scale

Objective: To assess quality of life of patients who underwent decompressive craniectomy (DC) for traumatic brain injury and satisfaction of caregivers with outcomes.Methods: This cross-sectional study was conducted at a tertiary care urban center in Pakistan. All patients with severe traumatic brain injury who underwent DC and survived \u3e6 months were included. Outcomes were assessed using 2 scales: Glasgow Outcome Scale Extended and Quality of Life After Traumatic Brain Injury (QOLIBRI). The proforma was translated and validated into the national language. Patient caregivers were interviewed to ask if they would opt for DC in a similar situation in future.Results: The study comprised 40 patients, including 35 male (88%) and 5 female (12%) patients. Mean age of patients was 26.5 ± 9.5 years. Mean Glasgow Coma Scale score at presentation was 8.34 ± 3.22. Median follow-up was 12 months (range, 6-18 months). Mean Glasgow Outcome Scale Extended score was 5.35 ± 1.9, which correlates with an unfavorable outcome. Mean QOLIBRI score was 59.65 ± 21.27. Family members of 38 (95%) patients were content with their decision to give consent for DC in their patients. Spearman correlation for different domains of QOLIBRI and Glasgow Outcome Scale Extended was statistically significant for all parameters except social relationship.Conclusions: Mean QOLIBRI score of patients undergoing DC was 59.65 ± 21.27. Most caregivers (95%) were satisfied with their decision to consent for DC. Patient-reported health-related quality of life assessment is necessary to assess impact of traumatic brain injury

Awake craniotomy for brain tumours in Pakistan: An initial case series from a developing country

Awake craniotomy offers safe resection of brain tumours in eloquent area. Aga Khan University Hospital, Karachi, recently started the programme in Pakistan, and the current study was planned to assess our experience of the first 16 procedures. The retrospective study comprised all such procedures done from November 2015 to May 2016. Pre-operative and post-operative variables were analysed. Of the 16 patients, 11(68.75%) were males and 5(31.25%) were females. The overall median age was 37 years (interquartile range[IQR]: 23-62 years). The most common presenting complaint was seizures 8(50%), followed by headache6(38%). The common pathologies operated include oligodendroglioma and glioblastoma. Pre-operative mean Karnofsky Performance Status score was 76±10, which increased to 96±7 post-operatively at discharge. Besides, 2(12.5%) intra-operative complications were observed, i.e. seizure and brain oedema, in the series. The study had median operative time of 176 minutes (IQR: 115-352) and median length of stay of 4 days (IQR: 3-7).Awake craniotomy was highly effective in maintaining post-operative functionality of the patient following glioma resection. It was also associated with shorter hospital course and so lower cost of management

Outcome of decompressive craniectomy in traumatic closed head injury

Objective: The aim of the current study was to observe functional outcomes of patients undergoing decompressive craniectomy (DC) for raised intracranial pressure (ICP) after blunt head injury and to assess possible predictive factors.Methodology: This study was a prospective cohort study which was conducted at Aga Khan University Hospital, Karachi over a period of 2 years (January 2015-December 2016). Adult patients, aged between 15 and 65 years of both genders undergoing DC during the study period were selected. Outcomes of DC were assessed at an interval of 3 months following injury using the Glasgow outcome score. The data were analyzed on IBM statistics SPSS version 21.Results: Seventy-two patients underwent DC for raised and refractory ICP. Glasgow Outcome Scale (GOS) at discharge, 1-month and 3-month follow-up were reported. GOS at 3-month follow-up showed 21 patients (29.2%) patients had a good recovery, moderate disability was reported in 16 patients (22.2%), and severe disability in 12 patients (16.7%), persistent vegetative state was seen in five patients (6.9%). Eighteen patients had in hospital mortality (25.0%). Tracheostomy and sphenoid fractures were found to be negative predictors of good functional outcome.Conclusions: DC is associated with an in hospital mortality of 25.0%. Favorable outcomes were seen in 51.4% patients. Tracheostomy and sphenoid fractures were negative predictors of good functional outcome. The results are comparable to international literature

Determination of factors associated with critical weight loss in oral cavity carcinoma patients: A retrospective cohort study.

Introduction  Critical weight loss is defined as an unintentional weight loss of ≥ 5% at 1 month or ≥ 10% at 6 months from the start of treatment. Critical weight loss leads to deterioration of the immune function and reduced tolerance to treatment (surgery ± radiochemotherapy) as well as increased complication rates. Objective  Critical weight loss, defined as a weight loss of ≥ 5% after 1 month or ≥ 10% after 6 months from the start of treatment, is not uncommon in head and neck cancer patients. We aimed to assess the factors associated with critical weight loss during the treatment of oral cavity squamous cell carcinoma patients. Methods  A retrospective cohort study was performed at the Aga Khan University Hospital, in Karachi, Pakistan, on 125 patients. Patients receiving adjuvant therapy were considered exposed, and the outcome was critical weight loss. Results  The mean age of presentation was 46.9 ± 12.8 years in patients undergoing surgery and adjuvant therapy, with 119 (79.3%) of them being male and 31 (20.7%) female. One hundred and twelve patients (81.3%) developed critical weight loss at 6 months from the start of treatment, and the only significant variable associated with critical weight loss was the stage of the disease ( p  = 0.03). Conclusion  A large proportion of patients with oral cancer developed critical weight loss requiring a need for intervention. The overall stage of the disease is a significant predictor of critical weight loss in patients undergoing treatment

Awake craniotomy in developing countries: Review of hurdles

Awake craniotomy is a neurosurgical approach, in which patient is operated under local anesthesia to assess his neurological function intraoperatively. It has multiple advantages over craniotomy under general anesthesia, mainly including improved postoperative neurological status, lower length of hospital, and lower overall cost of hospital stay. Awake craniotomy is commonly practiced in the developed world; however, its role in developing country is limited. Considering the benefits that awake craniotomy offers, it can contribute significant socioeconomic benefits to a developing country, especially with reduce expenditure on health care as well as maintenance of functional capacity of patients to continue work. Development of awake craniotomy in a developing country is a challenge. Multiple hurdles must be overcome before considering the possibility of the procedure. One of the key hurdles is limitation of resources. Others include neuroanesthesia training, extent of disease, and patient selection. Patient’s awareness or literacy rate is also a factor to be considered, especially in developing countries where it can be difficult to explain the procedure to the patient. The authors have successfully implemented awake craniotomy in Pakistan recently and have shared how they managed to overcome the hurdles in their case. The hurdles are considerable, but they can be overcome with efforts. The program will be highly beneficial to a developing country and should be attempted for betterment of health-care facilities available to the population

Screening for malnutrition in oral cavity cancer patients prior to treatment: A cross-sectional study

This study was conducted to assess the frequency of pre-operative malnourishment in patients being treated for oral cavity squamous cell carcinoma. A retrospective chart review was carried out at the Aga Khan University Hospital, Karachi, on 62 patients. Patients were screened pre-operatively through a standard nutritional assessment tool at the time of admission to assess for malnutrition. Mean age of presentation was 48.34±13.11 years, mean height was 165 ± 8.62cm, weight 66.09±14.98 kg and BMI of 24.09±4.84. Males were 82.3% and 17.7% were females. At the time of admission, a significant number or patients, 12 (19.4%) were prone to malnourishment, while 3 (4.8%) patients were malnourished: Assessment was done by using a standardised nutritional assessment tool

Evidence-based advances in glioma management

Glioma is primary brain tumors of the glial origin. Glioblastoma multiforme traditionally classified as Grade IV glial tumor carries the worst prognosis. Over the past decades, focus of the diagnosis and management has gradually shifted toward molecular and genetic profiling. This has been accompanied by advancement in radiology, radiation, and medical oncology. Despite significant progress in the individual disciplines, the overall prognosis has not increased significantly. There is consensus on the need of maximum safe resection for most of these tumors. Details of anatomy and white matter tracts obtained through preoperative imaging. These detailed radiological modalities allow the surgeons to plan a safe trajectory to the lesion, avoiding neurological complications. Five aminolevulinic acid and fluorescein guidance help increasing the extent of resection. Awake craniotomy with brain mapping has regained popularity for the safe resection of low-grade glioma, especially those located in eloquent areas. In this review article, we have discussed various aspect of glioma management including diagnosis and surgical resection

Spontaneous intraventricular hemorrhage: a rare presentation of a skull base mesenchymal chondrosarcoma

Abstract BACKGROUND: Chondrosarcomas are very rare malignant, slow-growing tumors that develop in or near the petroclival region of the brain. We report a very rare case in which the tumor originated from left petrous bone and induced intraventricular hemorrhage leading to an acute comatose presentation. CASE DESCRIPTION: A 28-year-old man initially presented to the outpatient department with a 1-month history of headache, vomiting, vertigo, and left facial numbness. A lesion at the cerebellopontine angle with extension into the middle cranial fossa was demonstrated on computed tomography and magnetic resonance imaging. The following night his condition worsened, and he presented to the emergency department with intraventricular hemorrhage with hydrocephalus. An external ventricular drain was placed in the emergency department to relieve hydrocephalus, and definitive surgical resection of the tumor was subsequently. Postoperatively, his Glasgow Coma Scale score improved, and he was transferred to the surgical intensive care unit where he remained for 3 days. He was subsequently stepped down to a special care unit and then to a ward room. The patient is currently awake and has grade II facial palsy (House-Brackmann), demonstrates spontaneous purposeful eye opening, inconsistently obeys single-step orders, demonstrates no meaningful phonation or vocalization, and has at least grade 4 power in all 4 extremities. He is currently fed through a nasogastric tube and is in rehabilitation. CONCLUSIONS: Our experience of petroclival junction chondrosarcoma causing intraventricular hemorrhage may be the first to be documented. Preferred treatment of this highly malignant lesion is radical removal with postoperative radiotherapy

The outcome and patterns of traumatic brain injury in the paediatric population of a developing country secondary to TV trolley tip-over

Background: Television (TV) trolley tip-over incidences are common and can cause significant morbidity and mortality in children. This study was aimed at analyzing the pattern and outcomes of head injuries resulting from TV trolley tip-over.Method: We conducted a medical chart review of children with TV trolley tip-over head injuries from January 2009 to April 2016. We collected data on demographics, the mechanism of injury, clinical and radiological features of the injury, and outcomes. Outcomes were measured by means of the Glasgow Outcome Scale (GOS) at 6 months (except in 1 case). A descriptive analysis was carried out using SPSS v19.Result: Twenty-two children were included in the study (median age 23.5 months). Sixteen children were male. Most of the children (n = 16) were aged 12-35 months. The median Glasgow Coma Scale score on admission was 15. The median Rotterdam Score for the patients was 2.0. Common symptoms upon admission were vomiting, irritability, scalp laceration, and bruises. Median length of hospital stay was 3 days. Skull bone fractures were present in 12 children. Other CT findings included contusions, extradural and subdural haematomas, intraventricular haemorrhage, and pneumocranium. Surgical intervention was required in 4 cases. Although most of the patients made a good recovery (GOS = 5), 1 patient developed a mild disability and another died in hospital.Conclusion: TV trolley tip-over is most common in toddlers and can lead to significant head injury and mortality. This can be avoided by parental supervision and adjustments in the household