Pakistan Journal Of Neurological Surgery
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Idiopathic Intracranial Hypertension (IIH) – Management with Lumboperitoneal Shunt: A Review of 50 Cases
Get PDFIdiopathic intracranial hypertension (IIH) is a syndrome of increased intracranial pressure without causative lesions of Brain on MRI or CT. A 5 year Study from Jan 2004 to December 2008 has been conducted at department of neurosurgery, Lahore general hospital, unit I. A total of 50 patients have undergone lumbo-peritoneal shunting for IIH., Predominantly patients were females i-e; 41 (82%) patients. Headache was present in all the 50 (100%). Headache associated with visual symptoms was present in 12 (24%). Patient. Patients selection was based upon positive response to lumbar Puncture or lumbar drain. Procedure was done through open method. Postoperative clinical improvement occurred in 46 (92%) patients. Worsening of the symptoms was noted in 1 (2%) patient.Conclusion: LP Shunt seems to be effective and safe procedure as the definitive measure in the management of IIH
Surgical Outcome of Otogenic Brain Abscess in Chronic Suppurative Otitis Media
Get PDFObjective: To determine the surgical out come of otogenic brain abscess in chronic suppurative otitis media.Material and Methods: This descriptive study was conducted at the departments of ENT, Head, Neck Surgery and Neurosurgery Postgraduate Medical Institute (PGMI) Lady Reading Hospital Peshawar from June 2004 to May 2009 with a total duration of five years. The diagnostic criteria were detailed history, thorough Neuro-otological examination and radiological investigations. These patients were admitted into ENT Department and they were put on quadruple therapy. CT scans were performed on emergency basis and as the patients were diagnosed as having otogenic brain abscess urgent evacuation of abscess was done by neurosurgeon. All the patients with established brain abscess were included in this study while those patients having small multiple abscesses, early cereberitis and non otogenic brain abscesses were excluded from study. A well informed consent was taken from patient explaining the procedure, its risks, benefits and associated complications. The abscesses were primarily treated by neurosurgeons and the ears were later on treated by ENT surgeons. There was neither intra operative nor postoperative complication.Results: This study included 22 patients in the age range of 12-51 years with mean age 25 years. Sixteen were male and six were female, with female to male ratio 1 : 2.6. These patients presented with history of discharging ear, headache, vomiting and disorientation. The signs of disease in these patients were granulation tissues/ cholesteatoma in ear and papilloedema. CT scans were performed in all 22 cases (100%) while MRI in 10 cases (45.45%). There were single brain abscess in 14 cases (63.63%) while 8 cases (44.45%) having multiple brain abscesses. Mainly abscess were found in temporal region followed by cerebellar. The patients with chronic ear disease were treated by radical mastoidectomy and modified radical mastoidectomy after treating the brain abscess by Neurosurgeon. The Neurosurgical procedures performed were capsulotmies in 13 cases (59.09%), Bur hole aspiration in 7 cases (31.81%) and Trans mastoid excision in 2 cases (9.09%). These patients were followed for 3 monthly having CT scan with contrast with bone window.Conclusion: We concluded from our study that otogenic brain abscess is a life threatening complication, so early identification with help of CT scan and prompt surgical intervention with appropriate treatment of middle ear (primary disease) is essential for better outcom
MVD as the First Line Therapy after Failed Medical Treatment; for Idiopathic Trigeminal Neuralgia
Get PDFObjective: To analyze the outcome of MVD as a first choice therapy when medical treatment has failed for the definitive management of Idiopathic Trigeminal Neuralgia.Material and Methods:Study was conducted at the Department of Neurosurgery PGMI / Lahore General Hospital, Lahore. This was a prospective observational case series from January 2007 to December 2008, 50 selected patients of Idiopathic Trigeminal Neuralgia diagnosed after radiological and clinical exclusion of secondary causes of Neuralgia presenting in whom medical management had failed were offered MVD as the first Intervention. All the patients were followed for one year post-operatively.Results: Mean age was 59.2 years and minimum age 47 year and maximum 72 years. There was 16 males (32.0%) and females were 34 (68.0%). Male to female ratio was 1: 2.16. In 15 (30.0%) patients facial pain was on left side and 35 (70.0%) patients had right sided pain. V1 was found in 1 (2.0%) patient, V3 in 2 (4.0%) pati-ents, V1 and V2 in 2 (4.0%) patients, V1-3 in 17 (34.0%) patients, V2,3 in 28 (56.0%) patients. An Arterial loop was found in 37 (74.0%) patients as the compressing agent and a Vein only in 4 (8.0%) patients. Mixed artery and vein in 8 (16.0%) patients. Thick arachnoid was the compressing agent in 1 (2.0%) patient. Out of 50 patients 46 (92.0%) had Excellent outcome, 3 (6.0%) patients had Good outcome, 1 (2.0%) patient was in Fair outcome group. No patients were in Bad and Failure outcome groups.Conclusion: Microvascular Decompression of trigeminal nerve is a safe and first choice therapy when medical treatment has failed for the definitive management of Idiopathic Trigeminal Neuralgia in otherwise medically fit patients provided Surgeon has adequate experience of performing the procedure
Post-Operative Visual Improvement in Pituitary Lesions after Trans-sphenoidal Surgery
No full textThe pituitary gland tumors are significant cause of endocrinopathies and visual field defects or decreased visual acuity. In pituitary macro-adenomas majority of the patients present with visual morbidity. These lesions may be clinically silent or may present with visual deterioration, hormonal disturbances and ocular palsies.Objective: To study postoperative visual improvement after trans-sphenoidal excision of pituitary macro-adenomas.Material and Methods: This was an interventional longitudinal study conducted in the department of Neuro-surgery, Lahore General Hospital Lahore affiliated with Postgraduate Medical Institute Lahore. Study comprises of 15 adult patients of both sexes harbouring functioning / non-functioning pituitary macro-adenoma having visual deficit presented to the department of neurosurgery, Lahore General Hospital, Lahore during the study period. Non-purposive sampling technique was used for sample selection by using a pre defined inclusion cri-teria. Visual acuity was measured by Snellen chart (Distant vision) Jaeger chart (Near vision) and base line was compared for improvement after surgery in terms of complete, partial, or no improvement. Post operative oph-thalmological examination were carried out on 1st post operative day, 1month, and 3 months of surgery, for to check improvement of vision and also improvement in visual field defects.Results: Mean age in our study of 15 patients was 37.8 years. The youngest patient was 17 years and oldest was 68 years. Gender distribution shows that 8 patients were females and 7 were males. The size of the tumor was as of MRI report calculated in centimeters. Mean tumor size was 3.10 ± 0.52 cm. Significant improvement was seen in visual acuity in right side eyes where as no significant improvement was seen in visual acuity in left side eye of patients.Conclusion: Our results suggest that the vast majority of challenging sellar tumors can still be resected safely, effectively, and efficiently with this approach and theoretical advantages of the approach are based on improved visualization and decreased tissue manipulatio
LP Shunt, the Treatment of Choice in Idiopathic Intracranial Hypertension. (A 5 Years Experience at Lahore General Hospital, Lahore)
Get PDFObjective: The history, diagnosis, and therapy of idiopathic intracranial hypertension (IIH) are reviewed. Theo-ries of pathogenesis are considered, the clinical presentation is described, and potential diagnostic and thera-peutic challenges are explored. Keeping in view all these things efficacy of L.P Shunt is observed.Material and Methods: A total of 35 patients were diagnosed as IHH according to the Modified Dandy’s criteria in our department from August 2007 to October 2012. An extensive literature review of IIH and related condi-tions was performed. The history of and rationale for the diagnosis and medical and surgical approaches to tre-atment are reviewed. Outcome of the patients’ with L.P shunt is observed.Study Design: Prospective and analytic study.Results: LP shunt addresses the cause of both headache and papilloedema more directly by effecting a global reduction of intracranial pressure. All patients underwent clinical, imaging, and CSF manometry evaluations. All patients showed failure or noncompliance to medical treatment and necessitated placement of an LP shunt. Among 35 patients who underwent LP shunt placement for IIH, 14 (40%) patients had severe and fulminant opening CSF pressures with values of more than 400 mm H2O. while in 21 (60%) patients opening CSF pressure was 260 to 400 mm H2O. symptoms of headache and papilloedema and visual obscuration improved in most of the patients. Shunt complications included two (0.7%) cases of shunt dislodgement and one (0.35%) case of shunt over drainage. Multiple potential contributing causes of intracranial hypertension must be excluded. On the basis of the advantages and disadvantages of different treatment modalities, we found L.P Shunt to be more effective and advantageous.Conclusion: Idiopathic intracranial hypertension is the diagnosis of exclusion. Medical therapy has a very little role in relieving signs and symptoms of this disease. L.P Shunt should be the treatment option in IIH
Vestigial Accessory Limbs with Spina Bifida: Our 5 – Year Experience
Get PDFBackground: Accessory limb on the back of trunk with spina bifida is an exceedingly rare entity which has perplexing morphogenesis. We are sharing our 5 – years’ experience of managing 5 patients with accessory vestigial limbs on the back associated with spina bifida.Materials and Methods: The medical record of 5 patients with accessory limbs on the back of the trunk was reviewed for mode of presentation, investigations, management, and outcome.Results: There were 5 infants, one was male while rest were females (M: F = 1: 4). Ages ranged from 1.5month to 1 year (mean age 6.3 months). All patients presented with a vestigial limb attached to the lumbosacral region. One patient had anal pit like depression on the vestigial accessory limb. Every patient had associated spina bifida. One patient had associated lipomeningocele. Another patient had associated right clubfoot. All patients were investigated with X-rays and MRI and underwent excision of the accessory limbs. One patient developed wound dehiscence and CSF leak post-operatively which settled on conservative management. Stillanother patient had repeated wound infections and is booked for release of tethered spinal cord. All patients survived. Two patients required physiotherapy for lower limb weakness.Conclusion: Accessory limbs on the back are quite rare anomalies and are associated with a number of other anomalies. It is more common in females. The anomaly is a psychosocial dilemma for the parents. Early excision is necessary to allay the anxiety of the parent
Patterns and Association of Pediatrics Head Injury Due to Fall in Accordance to Height
Get PDFBackground and Purpose: The authors conducted a study to describe the patterns and association of fall related head injuries in pediatric population and also to compare it with the western world.Methods: We performed a retrospective analysis of all patients less than 15 years of age treated for fall – related trauma between June, 2009 and September, 2011. Falls were classified as low (12 feet) and high level (more than12 feet).Results: Eight hundred and sixty cases were identified with a mortality rate of 6.7%. A fall of greater than 12 feet (high – level fall) was associated with a higher mortality rate than low – level falls 52 (5.7% Compared with 5 (1.0%), respectively). Two Hundred and twenty eight patients had sustained a skull fracture (150 children had a depressed skull fracture) and 80 patients had basal skull fracture, 46 patients had suffered a cerebral contusion, 25 subarachnoid hemorrhage, 42 subdural hematoma, and 82 had an epidural / extradural hematoma. One hundred twenty patients required surgery for traumatic injuries of these, 80 underwent craniotomy for evacuation of a blood clot. Height was not predictive of the Glasgow Coma Scale (GCS) score. In all 15 deaths resulting from a low – level fall there was an admission GCS score of 4/15, and abnormal findings were demonstrated on computerized tomography scanning. Death from high – level falls was attributable to either intracranial injuries (50%) or severe extra-cranial injuries (50%). Intracranial injury is the major source of fall – related death in children and, unlike extra-cranial insults, brain injuries are sustained with equal frequency from low – and high – level falls in this population. Height was not predictive of the Glasgow Coma Scale (GCS) score. In all 15 deaths resulting from a low – level fall there was an admission GCS score of 4/15, and abnormal findings were demon-strated on computerized tomography scanning.Conclusion: The GCS scores obtained in patients who sustained a Low – level fall were a poor predictor of intracranial bleeding. In 47% of these patients with intracranial bleeding an Emergency room GCS score of 13 to 15 was determined. A high GCS score does not therefore; eliminate the need for performing head CT scanning, even after the patient suffers a low level fall. We found a high percentage of intracranial bleeding/cranial frac-tures in patients falling from low height. Physicians should obtain a brain CT scan in pediatric fall victims. A proper trauma protocol should be followed and made in accordance of our need and standards
Incidence and Management of Dural Tears in Degenerative Spinal Surgery
Get PDFObjects: The purpose of this study was to study the incidence, results and treatment of Dural Tears sustained during operation on lumbar spine for degenerative spine diseases in peripheral teaching hospital.Study Design: This was an observational descriptive study.Materials and Methods: This study was conducted in the Department of Neuro Surgery Saidu teaching Hospital swat from Jan 2007 to Dec: 2010. During this period a total of 305 patients underwent spinal surgery were included in our study. Preliminary preoperative imaging and preparation was performed in these patients.Results: A total of 305 patients including in this study. The male female ratio was 1:1.67% out of 305 patients primary surgery was performed in 238 patients while revisional surgery was perform in 67 cases. a total of 29 cases had dural tears, in 27 patients Dural tear was recognized preoperatively out of which 21 tears where repaired and 6 patients were treated conservatively. Conservative treatment was not successful in these 6 patients and they underwent Re exploration and repair. In 2 cases dural tears were diagnosed latter on due to CSF leakage in 1 case pseudomeningocele is 2nd cases conservative trial failed have both were reoperated for dural repair.Conclusion: Dural tears is more common in revisional surgery and all Dural Tears should be repair
Management of Cervical Neurofibroma Type
Get PDFObjective: To determine the clinical presentation and postoperative outcome of cervical neurofibroma type 1.Study design: Retrospective study.Place and Duration of Study: Hayatabad Medical Complex Hospital Peshawar Khyber pakhtoonkhawa from 1st February 1999 to 31st July 2011.Material and Methods: A total 41 patients with symptomatic cervical spine neurofibromas who underwent surgical decompression and tumor resection were included in this study. Both gender (male and female) and patients in the age range of 20 – 70 years were included in this study. These patients were operated through posterior approach of the cervical spine and then followed for six months for postoperative outcome .The patients’ demographic details and clinical manifestation were entered into a semi structured proforma. Data was analyzed through statistical program SPSS version 11.Results: Out of 41 patients, there were 22 (53.6%) males and 19 (46.3%) females. The age of patients ranged from 20 to 70 years. In this study the overall mean age was 39.2 years. Majority of patients 19 (46.3%) were in the age range of 31 – 40 years. Most common clinical presentation of patient were quadrapresis in 23 (56.1%) pain neck 9 (22%) paraparesis 9 (22%) patients. Postoperatively most of the patients recovered from their preoperative symptoms.Conclusions: Quadraparesis and pain neck were the common clinical presentation of cervical cord neurofibroma type 1. Surgical outcome of cevical neurofibroma type 1 is good
Multidisciplinary Approach for the Management of Brain Arteriovenous Malformations
Get PDFObjective: The main Objective of this study was to evaluate the significance of multimodality treatment of AVMs.Material and Methods: The data for this study was collected from the four years audit of surgical management of Arterio-venous Malformation in King Faisal Specialist Hospital and research center Jeddah, from year 2014 to 2017 which include 24 patients with brain AVMs.Results: In our study equal no. of male and female patients were recorded i.e. 12 patients in each group (50.00%). Seventeen (70.83%) patients were found in the first three decades of life indicating that the disease affects the younger age group. Main presenting complaint was seizures that was noted in 16 patient (66.66%) while headache was present in 15 patients (62.50%) followed by other signs and symptoms. Treatment of the patient was tailored according to the type of AVM its grade and the best possible way to take the complex disease. It included combination of pre-surgical or post-operative embolization, Complete of partial surgical resection of the lesion and stereotactic radiosurgery. The combination of these modalities were employed according to the situation of the patient to keep the plan of treatment safe, affective and ending finally in exclusion of the disease from the brain circulation. Pre-surgical embolization was successfully done in 7(29.16%) patients wile surgical resection was done in all patients at different stages of treatment. With use of multidisplanary approach in this series; Improvement was seen in 16 (66.66%) of the patient, 6 (25.00%) revealed no improvement while one patient (04.16%) was deteriorated.Conclusion: It was concluded that tailoring the treatment plan and use of multidisciplinary Approach for the management of Brain AVM depending upon their initial grades according to Spetrelz Martin grading system results in maximum favorable results