Pakistan Journal Of Neurological Surgery
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Comparison of Outcome of Chronic Subdural Hematoma (SDH) In Terms of Recurrence with Drain and without Drain
Get PDFBackground/Objectives: Chronic subdural hematoma commonly reported in neurosurgical practices. Variations are reported in neurosurgical practices regarding the treatment of chronic subdural hematoma (SDH). This study determined the outcomes of SDH with Drain and without Drain in terms of recurrence and effectiveness.
Material and Methods: A randomized control trial was conducted in the Department of Neurosurgery Ayub Teaching Hospital Abbottabad. Group-A patients were subjected to drainage of chronic subdural hematoma without drain and Group-B patients were subjected to drainage with drain. All patients were followed up to one month for recurrence of subdural hematoma like on CT-scan.
Results: Overall, the recurrence of chronic subdural hematoma in both groups was seen in 16.7% of patients and the procedures were effective in 83.3% of patients. In Group A, 79.6% of patients were successfully treated through burr hole with irrigation, while 20.4% of patients had recurrent chronic SDH. In Group B, only 13% of patients had a recurrence, while 87% of patients were successfully treated with burr with the closed continuous drainage system. An insignificant difference (p-value: 0.302) existed between groups for both types of procedures.
Conclusion: The patients who were treated with burr hole and irrigation of the subdural space with normal saline had high recurrence incidence than those with burr hole with closed continuous drainage system
Pediatric Head Injury: A Study of 120 Cases
Get PDFObjectives: This study aimed to evaluate incidence, mode, and severity of injury, treatment options and to determine the outcome in pediatric age group patients with head injury.
Patients & Methods: 120 pediatric patients with a head injury, with ages up to 15 years or less, were included. Detailed history, general and neurological examination including GCS were noted. The CT scans were conducted and the patients managed as per said protocol. Various surgical procedures were performed including craniotomies and evacuation of hematoma, the elevation of depressed fractures and repair of the dura, decompression craniotomies, and evacuation of Subdural collections and contusions.
Results: 60.1% of patients were boys and 39.16% were girls. In the majority (63%) of the children, the ‘fall’ was reported. The majority of children (68.3%) in our study had a mild head injury with GCS 13 – 15. 35.83% patients had normal CT scans, and 23.33% had isolated skull fractures. 68.75% patients were with a severe head injury and had a poor outcome. A poor outcome was noted in patients having brain edema, subdural hematoma, and brain contusions.
Conclusion: Head injury in the pediatric age group still continues to be a significant cause of mortality and morbidity. The outcome is directly being related to the severity of injury i.e., GCS. Falls and RTAs are the most common causes and preventive measures in different forms need to be addressed
Shunt Migration into Scrotum: A Case Report
Get PDFVentriculoperitoneal shunting (VPS) is a common procedure involved in the management of hydrocephalus. VP shunt has many inherent complications including obstruction, infection, breakage, and migration of the shunt. The incidence of scrotal shunt migration is around 14% VPS migration into the scrotum manifests as reducible trans-illuminant scrotal swelling, which is more like hydrocele. Mostly migration occurs into the right hemi-scrotum within the first 6 months of performing a ventriculoperitoneal shunt. Bilateral herniotomy with repositioning of the distal shunt catheter is the treatment of choice
Abdominal Aortic Pseudo-Aneurysm, a Dreadful Complication of Caries Spine – A Case Report
Get PDFThe thoracic spine is the most frequently involved region in carries spine, 60 percent; and in the thoracic spine, more than 70 percent occur in the midthoracic regions D8, 9, 10. The cauda equine and lumbosacral involvement frequency are less frequently involved. But the vascular complication it causes is a rare disease, with high mortality when it involves adjacent critical vascular structures like the abdominal aorta with complicating aneurysm and pseudoaneurysm. Evaluating a patient with a caries spine starts with a thorough history, physical examination findings, laboratory investigations like CBC, ESR, CRP, ICT TB, etc., complete radiological workup like X-rays, 3-D CT reconstruction of the whole spine, MRI whole spine with and without contrast. We presented a case of 21 years male who was suffering from caries spine, at D11 – D12; which had eroded his abdominal aorta secondary to bony spicules of carries. This erosion of the aorta had blood leak into psoas muscle, which was mimicking psoas abscess on preoperative CT scan spine, and MRI whole spine. During corrective surgery for his caries spine, unexpected torrential bleeding was encountered, when the left psoas muscle was given nick. Bleeding was stopped with packs and with the help of a cardiac surgeon. Postoperatively the patient was kept in ICU, but unfortunately on the 8th post-surgery patient succumbs to his illness. In our case, psoas muscle pseudoaneurysm was missed radiologically in both MRI and CT spine preoperatively. Angiography with endovascular aortic stenting would have changed the surgical course of the patient
Clinical Outcome and Complication of Endoscopic Endonasal Transsphenoidal Surgery (ETSS) for Pituitary Adenoma: A Retrospective Study at Prime Teaching Hospital Peshawar
Get PDFObjectives: The study aimed to ascertain the clinical outcome and complications of endoscopic endonasal transsphenoidal surgery (ETSS) for pituitary adenomas.
Material & Methods: A retrospective study conducted at the Department of Neurosurgery Prime Teaching Hospital Peshawar, Pakistan. Pituitary adenoma was diagnosed in 89 patients on MRI Brain with contrast and post-surgical biopsy. Post-surgical outcomes and complications were documented.
Results: Out of 89 patients, 54% were male, and 46% female patients. The mean age was 42 ± 5 years. Headache was reported in 92% as a most common presentation, followed by decreased visual acuity in 62 %, amenorrhea in 22%, and acromegaly in 29% of patients. Overall, the symptoms related to surgical improvement were observed in 72% of patients. A good surgical outcome was observed in 80% of patients with microadenomas, as compared to the patients with macroadenomas. The most common complication was the transient diabetes insipidus followed by Cerebrospinal fluid (CSF) leak and post-operative hematoma.
Conclusion: Endoscopic endonasal transsphenoidal surgery (ETSS) is a safe, less invasive, cosmetically effective technological advancement for pituitary adenomas
Glue That Pain: A Case Report and Review of Literature
Get PDFTarlov cysts are cystic lesions of the nerve root sheath in the lower spine. With a reported incidence ranging from 1 to 5%, these lesions are fairly rare, benign and often asymptomatic. When they cause neural compression they may become symptomatic with sensory, motor, bowel/bladder and sexual dysfunction. The treatment of symptomatic Tarlov cysts is a controversial issue, ranging from conservative management and local steroid injections to a bewildering assortment of surgical options including CSF diversion procedures and advance microsurgical approaches with various ways of cyst manipulation. All these surgical modalities carry a high risk of serious complications, recurrence with need of a redo operation and a very variable rate of symptomatic relief ranging from 38 – 100 % in different series. Developing from the CT guided needle aspiration of the cyst which suffered disappointment in the form of re accumulation and heralded by earlier reports of aseptic meningitis, CT guided aspiration and subsequent filling of the cyst with fibrin glue has now emerged as a safe, highly effective and first line of treatment for symptomatic Tarlov cyst
Assessment of Modes of Injury and Outcome in Patients with Traumatic Posterior Fossa Extradural Hematomas: A Study of a Tertiary Care Hospital
Get PDFObjective: The aim of study to assess the prevalence of divergent modes of injuries in traumatic posterior fossa extradural hematomas (PFEDH) along with the description of surgical and clinical management.
Material and Methods: A descriptive study was performed at the Jinnah Postgraduate Medical Centre (JPMC), Karachi from May 2014 to October 2020. Total 37 patients who presented with posterior hematoma of any age and gender were included. CT scan Brain plain with the bone window was performed for a basic diagnosis to assess the volume, and any associated fracture, or any injury in the posterior fossa. The outcome was calculated from the scores of the Glasgow Coma Scale (GCS).
Results: 70% were male and around 30% were female patients. The mean calculated age was 32 ± 5.33 years. A road traffic trauma was the major cause of brain injury in 25 (67.56%) cases. The majority (56.75%) of patients reported headache, nausea and vomiting. 35% of patients were conservatively managed, with an average hematoma size of 3 cm on CT scan and GCS > 12 while 64.86% patients were operated, with the average size of hematoma > 3 cm and GCS < 10 while 61% of the patient had an occipital fracture. The majority of patients (8.1%) reported complications such as brain contusions and post-traumatic hydrocephalus.
Conclusion: Post fossa EDH should be managed aggressively, especially those with low GCS (< 8), and volume > 3 cm. Patients who are to be managed conservatively also require close observation.
 
Medico-Legal Cases (MLC) Presented at a Tertiary Care Center and Acute Symptoms of Post-Traumatic Stress Disorder among the Survivors
Get PDFObjectives: An observational, prospective study was conducted to determine the incidence and risk factors associated with victims of physical assault and symptoms of post-traumatic stress disorder (PTSD).
Material & Methods: All the registered medico-legal cases reported to the emergency department of Gambat hospital were included in the study. The data was collected on a predefined questionnaire including age, gender, mode of injury, weapon of the injury, type of assault (blunt or penetrating), firearm injuries, and road traffic accidents from medico-legal registers. Impact of Event Scale (IES) was used to assess Post-traumatic stress disorder.
Results: The mean age (SD) of victims was 29.3 (10.25) years. Blunt injuries were experienced by 47 (31.33%) victims. The majority of the victims suffered road traffic collision injuries, 59 (39.33%). Forty-eight (32%) victims had substantially higher IES scores (above 37) that confirmed severe PTSD that may contribute to the suppression of the immune system’s functioning among survivors. The majority of the victims were between 18 and 40 years.
Conclusion: The most common cases were related to road traffic collisions followed by blunt injuries. The incidence rate of PTSD was also prevalent in these individuals. Thus, strategies should be developed to prevent such incidents and those who suffer from such traumatic events must be offered psychiatric consultation
Minimal Invasive Surgery for Chronic Subdural Hematoma
Get PDFObjective: To assess significant improvement in terms of the Glasgow Coma Scale in patients subjected to minimally invasive surgery for a chronic subdural hematoma.
Materials and Methods: A total of 80 patients with chronic subdural hematoma (CSDH) were enrolled in a sequential fashion using a retrospective study design. The patients were treated with minimally invasive surgery (MIS) and assessed at the end of the 2nd postoperative day (POD) for any significant improvement in the Glasgow coma scale (GCS).
Results: There were 76.25% male and 23.75% female patients. A maximum number of patients (42.5%) were found with a GCS ranging from 9/15 – 11/15 (Class B) followed by Class A having GCS 12-13 (36.25%) and then Class C with GCS 5 – 8 (21.25% patients). In 86.2% and 13.7& of the patients, positive and negative outcomes were recorded. Maximum favorable surgical outcome was observed in 51-60 years of age group. In the majority of male patients, a favorable surgical outcome was reported. Similarly, a favorable surgical outcome was observed in Class B (GCS 9-11). There existed an insignificant difference between favorable surgical outcome vs. age groups, gender, and GCS class at baseline.
Conclusion: This study found that CSDH using the MIS approach is linked to a high frequency of positive outcomes in terms of GCS improvement. A lower admission GCS score and older age are linked to a lower frequency of favorable outcomes and a higher likelihood of bad outcomes
Experience with Ventriculoatrial Shunt: A Valid Option.
Get PDFCerebrospinal fluid (CSF) diversion through shunting, either internal or external, is the standard of care for hydrocephalic patients. Although Ventriculoperitoneal (VP) shunt is always the first choice, right atrium for Ventriculoatrial (VA) shunt is considered a suitable and convenient option for drainage of excess CSF in patients with history of abdominal surgeries, peritoneal infection or shunt obstruction.1 Here we are reporting our experience with a patient who underwent VA shunt insertion because of a previous malfunctioning VP shunt. A thorough review of the literature revealed that, although reported worldwide, there is an apparent deficiency of similar reports from Arabian Gulf region. Through this case report, we aim to shed light on this internal CSF diversion method, which could be considered in centers lacking advanced care facilities for procedures like Endoscopic 3rd Ventriculostomy (ETV)