Interesting neurosurgey cases in KIMS hospital nellore

Neuro surgery cases

1. Interesting case scenarios Dr.K.Uday kiran Consultant neurosurgeon KIMS hospital Nellore

2. Case 1 Case 2 is a patient with acute onset left hemiparesis and dysarthria with eye signs .

3. ACUTE RIGHT THALAMIC HEMORRHAGE , INTRAVENTRICULAR EXTENSION , MILD ODEMA

4. Thalamic haemorrhage may cause a wide variety of neurological signs, including contralateral hemiparesis , contralateral hemisensory loss, aphasia,movement disorders, abulia , stupor, and inattention. Neuro -ophthalmological manifestations of thalamic stroke are common and include oculomotor disturbances in both the vertical and horizontal planes , homonymous field defects, visual neglect, and pupillary abnormalities.

5. PSEUDO-ABDUCENT PALSY abduction deficits( pseudoabducens palsy).

6. “Peering at the tip of the nose ” sign reflecting acute downward and medial deviation of the eyes is highly suggestive of thalamic haemorrhage

7. They most often occur as a result of extension to or compression of mesencephalic-diencephalic junction or adjacent dorsal midbrain which contains structures important for vertical gaze and vergence .

8. Inhibitory pathways for vergence Damage

9. Take home message Awareness of this sign may assist clinicians with the correct anatomical localisation of stroke in patients who present with thalamic haemorrhage . The “peering at the tip of the nose” sign is a reliable clue to the presence of a lesion located around the mesodiencephalic junction, most commonly a thalamic haemorrhage . Clinicians may have difficulty with anatomical localisation of thalamic haemorrhage if they are not aware of this sign.

10. Case 2 Young male 22years old. Swelling in the left thigh associated with Severe pain . Left foot drop. No constitutional symptoms . FNAC done and the swelling is reported as nerve sheath tumor - schwannoma

11. mRI LEFT THIGH

12. Intra–op pictures

13. Hpe – biopsy Nellore – rhabdomyosarcoma opinion 1 -- round cell tumor opinion 2 Higher centre for specific markers – conclusion is EXTRA SKELETAL EWINGS SARCOMA

14. fluorodeoxyglucose ‑ positron emission tomography (FDG‑PET) DONE METASTATIC DEPOSIT IN SCAPULA. CHEMOTHERAPY

15. literature Extraskeletal Ewing sarcoma (EES) is a relatively uncommon primary tumor of the soft tissues, which accounts for 20‑30% of all reported cases of ES. EES is a rapidly growing mass that causes localized pain. It develops within the soft tissues of any anatomic areas most common sites include the upper thigh , buttocks, upper arm and shoulders. Conversely, metas ‑ tases are commonly observed in the lungs, bones and bone marrow

16. Definitive treatment for localized disease include chemotherapy and surgery . Radiation therapy is effective in unresectable diseases. The prognosis of EES is more favorable compared with the skeletal subtype The 5‑year overall survival rate is superior for localized EES compared with localized skeletal ES. Metastatic disease is a bad prognostic factor.

17. Thank u