Pakistan Journal Of Neurological Surgery
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Early Postoperative Complications Following Myelomeningocele Repair
Get PDFIntroduction: Neural tube defects are one of the most common congenital anomalies which frequently needs operative intervention for the anomaly correction. Complications can arise in these paediatric patients peri-operatively which require special considerations.Materials and Methods: After taking informed consent patient data was gathered in pre-designed pro-forma. After MMC repair patients were followed till the time of discharge and up to 1 month afterwards and record made of any early postoperative complications. Data was gathered about patient demographics along with postoperative recovery variables. Analysis of the data was done using SPSS version 20.0. Data was presented using graphs, charts and figures.Results: 197 patients were included in the study with 54.31% males and 45.69% females with mean age of 71.4 days ± 61.9 SD. 68.5% patients developed at least some form of complication. The most common postoperative complication was hydrocephalous (57.4%) which was followed by postoperative fever (27.4%). VP shunt was inserted in 50.3% patients. There was no significant association between age or gender to the occurrence of complications (p = 0.85 and 0.47 respectively).Conclusion: Since majority of infants die within the early postoperative period we should be vigilant regarding developments of these complications and minimising them. By documenting the early postoperative compli-cations, the surgical teams can improve their outcome
Frequency of Common Computed Tomography Findings among Clinically Undiagnosed Patients of Acute Severe Headache
Get PDFIntroduction: Headache is the commonest neurological symptom seen in general practice. Lifetime headache in general population of UK is over 90% prevalent. The most common cause of such headaches is sub arachnoid hemorrhage. Early and accurate recognition and diagnosis of such headaches is very important as it is indicative of serious underlying disorder.Objective: To determine the frequency of common computed tomography (CT) findings among clinically undiagnosed patients of acute severe headache.Materials and Methods: There were 203 CT scan of clinically undiagnosed patients of acute severe headache, performed after consent from the patients. All the CT reporting were done by single experience radiologist and findings were recorded. The study was designed as Cross sectional descriptive study from February 2017 to September 2017 at department of Radiology, Lady Reading Hospital Peshawar.Results: Out of total 203 patients, male to female ratio was 0.87:1. Average age of the patients was 35.38 ± 10.83 years with age range of 18-60 years. The commonest radiological finding was sub arachnoid hemorrhage which was observed in 49 (24.1%) patients.Conclusion: CT finding shows that sub arachnoid hemorrhage was found in majority of clinically undiagnosed patients of acute severe headache
Language and Visual Deficits after Parietal Lobe Glioma Microsurgery
Get PDFObjective: To see language and visual field outcome after high grade glioma excision of parietal lobe area.Study Design: It was observational experimental study.Setting: Department of neurosurgery unit 1, Lahore General Hospital, Lahore.Duration: Three years from March 2015 to April 2018.Inclusion Criteria: Both male and female of 13 to 56 yrs of age having intrinsic tumours in left or right parietal lobe area with midline shift, seizure and headache.Exclusion Criteria: Butterfly glioma, gliomatosis cerebri, lymphoma suspected on MRI brain, patient unfit for anaesthesia and surgery. The patients on anticoagulants and with bleeding disorder were also excluded from the surgery. The patients with chronic systemil ailment like renal failure, liver failure and ischemic heart disease were also excluded from the study.Material and Methods: Two hundred and forty one (241) patients were included in the study. All patients were prepared for the surgery and informed consent obtained from all patients. All patients under went microsurgical excision of the tumours and followed for 3 months. But forty patients lost to follow-up in three months.Results: Maximum tumor resection was attempted up to 99 percent. Median age was 47 years (13 – 56 years) and kernofsky performance scale was 75 percent at presentation. Most common presentation was seizure 76 percent, only 3.5 percent presented with parietal lobe syndromes. The most common deficit was language disturbance, which was also noticed in patients with right parietal lobe gliomas. Parietal lobe gliomas produce language and visual deficits in addition to other neurological dysfunction.Recommendations: Result can be improved by preoperative better localization with diffusion tensor tractography and peroperative cortical mapping.Conclusions: Microsurgical resection would increase language and visual deficits in tumors located on supramarginal and angular gyri which are reduced in postoperative period and become fixed in three months
Complications Following Posterior Fossa Tumour Surgery in Children: Experience from a Tertiary Care Neurosurgical Facility in a Developing Country
Get PDFBackground: Posterior fossa tumours are the commonest childhood brain tumours with diverse clinical presentations, treatment modalities and postoperative outcomes. The literature has limited description of postoperative complications following surgery for these tumours. Objective: The aim of this study is to analyse the postoperative complications, which occur after PFT surgery in children. A brief overview of the in-hospital mortality and management of these complications presented. Materials and Methods: This is a retrospective chart review of children who were operated for PFTs. The occurrence of complications during the postoperative period was noted. Complications management, in-hospital mortality and overall survival was also recorded until the time of discharge. The complications are divided according to the modified Clavien-Dindo classification and outcome was stratified accordingly. Results: 79 (60.3%) males and 52 (39.7%) females with a mean age of 8.15 ± 3.3 years. The mean duration between symptoms onset and diagnosis was 35.3 ± 16.6 days. Overall, there were 53 (40.5%) cases of medulloblastoma, 40 (30.5%) cases of ependymoma, 34 (26.0%) cases of pilocytic astrocytoma and only 4 (3.1%) cases of atypical teratoid/rhabdoid tumours. Twenty-five (19.1%) patients developed hydrocephalous postoperatively. The most common complication was postoperative incisional CSF leak, which occurred in 17 (13.0%) patients. Wound infection was noted in 8 (6.1%) patients, eight (6.1%) of patients presented with cerebellar mutism, five (3.8%) patients had bleed in tumour bed, five (3.8%) patients had aspiration pneumonia and 7 (5.3%) patients developed hospital acquired pneumonia. The overall mean length of stay (LOS) was 5.4 ± 2.2 days (range: 3 – 12 days). The overall mortality rate was 9.9% (n = 13). Conclusion: The most common complication is the development of hydrocephalous, followed by cerebrospinal fluid leaks, cerebellar mutism, peri-tumour oedema, tumour bed haematoma and systemic complications such as meningitis, sepsis and postoperative pneumonia. 
National Neurosurgical Activities
Get PDFNeurosurgery is an inherently dynamic specialty, developing at a very rapid pace, more so because of the involvement of and its dependence on advanced technology. The international neurosurgical scene is full of cutting edge research presented in dramatic meetings, conferences, workshops and courses. The local neuro-surgical landscape is no exception. Its panorama is changing as the development of neurosurgery is gaining pace in Pakistan. Prospects look good considering the fact that the activity on the academic front is also getting richer. The following compilation of the individual events gives a flavour of this richnes
Depressed Skull Fracture Management of 100 Cases at DHQ Teaching Hospital/Sahiwal Medical College Sahiwal
Get PDFAims: Aim is to study the presentation and management of patients with depressed skull fractures at DHQ Teaching Hospital/Sahiwal Medical College Sahiwal.
Materials and Methods: Elevation and repair of an open depressed skull fracture is often of as an emergency procedure. Common indications for emergency elevation of depressed skull fracture have been Dural tear, gross contamination, mass affect from depressed bone and/or sizable underlying extradural collection. Surgery may be performed if patient gets seizures and develops depression of skull especially frontal region which needs surgery for cosmetic reasons. Over a period of four years one hundred patients with depressed skull fractures were admitted in Neurosurgery department from July 2011 to June 2015.Mode of injury, clinical presentation, site and side of depressed skull fracture were noted. X-skull and C T scan brain was done in all cases to confirm the diagnosis and to see the underlying brain injury.
Results: Pre-operative GCS score was from 6 – 15. Focal neurological deficit was present in 16 cases. Surgical management done was wound debridement, elevation of depressed bone pieces, repair of Dura and evacuation of underlying hematoma. Fourteen patients developed different complications which were managed successfully.
Conclusion: Depressed skull fracture is a neurosurgical emergency which needs early operation to reduce the incidence of infection. Wound wash, debridement and elevation of depress fragment is treatment of choice along with Dural repair and/or evacuation of underlying hematoma as/if needed
SuprasellarArachnoid Cyst as a Cause of Triventricular Hydrocephalus, Found Incidentally During Endoscopic Third Ventriculostomy
Get PDFBackground: Arachniod cyst is a rare congenital disorder of the brain accounting 1% of all intracranial masses. They may also be acquired following head trauma, meningitis, tumors or surgery. They may be the cause of triventricular hydrocephalus (TVH). It occupies the third ventricle so flow of CSF is obstructed at aqueduct of Sylvius. Per operatively, it differs from colloid cyst in consistency, its capsule is transparent and blood vessels are visible.
Objectives: To determine the frequency of suprasellar arachnoid cyst as cause of triventricular hydrocephalus and outcome of ventriculocystocisternotomy performed for these cysts at Lady Reading Hospital, Peshawar.
Materials and Methods: A retrospective study of 18 cases who undergone ETV for congenital TVH from January, 2013 to December 2015 at Neurosurgery department LRH was performed. On pre operative CT scan brain they were having triventricular hydrocephalus. Ventriculocysto-cisternotomy was performed in all these cases. Biopsy was taken in all cases.
Results: Out of these 18 cases, 11 (61%) were males. The presenting symptoms in our study were that infants presented with increased head circumference (n = 3) 16.6%. In pediatric and middle age group the symptoms were those of elevated ICP (n = 13) 72.22%. No endoscopic complication occurred during the procedure except for clinically non-significant bleeds. We followed all cases for a period of 6 months. Clinical and radiological improvement occurred in all cases.
Conclusion: Arachnoid cyst should also be considered as a differential for congenital TVH. Endoscopic Ventriculocystocisternotomy is the treatment option of choice forsuprasellararachnoid cyst.
Abbreviations: TVH: Triventricular Hydrocephalus. CSF: Cerebral Scleral Fluid. ICP: Intracranial Pressure. AC: Arachnoid Cyst. SSCs: Suprasellar arachnoid cysts. VC: Ventriculocystostomy. VCC: Ventriculocystocisternotomy. CT: Computer Tomography
Outcome of Suboccipital Decompression with and without Duraplasty in Adults with Chiari I Malformation
Get PDFObjective: To investigate outcome for Arnold Chiari 1 Malformation (ACM1) patients based on intervention methods, i.e., posterior fossa decompression without duraplasty and with duraplasty in terms of symptomatic and functional improvement
Materials and Methods: This study was conducted prospectively over 41 months from January 2013 to May 2016. Patients with confirmed diagnosis of ACM-1 were included in the study. Patients either underwent posterior fossa decompression without duraplasty or with duraplasty, depending upon the severity of tonsillar descent, the presence of syrinx, neurological deficits or hydrocephalous. Data was collected on pre-designed pro forma both pre-operatively and during follow up. Outcome was assessed according to Chicago Chiari Outcome Scale (CCOS). Data analysis was done using SPSS v 22.0.
Results: Posterior Fossa Decompression (PFD) without dural opening was performed in 13 patients while in 8 patients duraplasty was performed. Overall mean age was 32.95 ± 5.88 years and mean symptoms duration was 21.62 ± 8.82 months. The most common complaints were headache (76.2%), neck pain (61.9%), hand and arm weakness (47.6%), gait disturbance (47.6%) and cranial nerve dysfunctions (76.2%). The median preop CCOS was 10 ± 1.57 while postoperative CCOS was 13 ± 2.27. There was a significant relief in terms of CCOS improvement in preop and postoperative scores (P = 0.006). The commonest complication was CSF leak in 14.3% of patients. There was no mortality. No recurrent cases were noted during the 41-months study period.
Conclusion: Posterior fossa decompression forACM-I is simple and effective. Further studies regarding surgical outcome and development of outcome assessment are required with larger patient cohorts.
Abbreviations: CCOS: The Chicago Chiari Outcome Scale. CSF: Cerebrospinal Fluid. CV: Craniovertebral. OPD: Out Patient Department. SD: Standard Deviation. HMC: Hayat Abad Medical Complex. ACM1: Arnold Chain 1 Malformation
Role of Emergency Decompressive Craniectomy in Patients of Traumatic Brain Injury
Get PDFObjective: To study the role of emergency decompressive craniectomy in patients of traumatic brain injury.
Methodology: This observational study was performed in the department of Neurosurgery, MTI, LRH, Peshawar, from 1st February, 2016 to 31st January, 2017. A total of 28 patients of traumatic brain injury, who underwent emergency decompressive craniectomy within 24 hours of their admission were included in the study after applying the inclusion and exclusion criteria. A questionnaire was used to document the data. Data analysis was performed with the help of SPSS version 20.
Results: The total no. of patients were 28, out of which 21 (75%) were male and 7 (25%) were female. The mean age of all the patients was 31 ± 19.84, with a range of 10 – 80 years. The preoperative diagnosis was acute subdural hematoma (ASDH) in 15 (53.6%), large contusion in 6 (21.4%), post-traumatic intracerebral bleed in 3 (10.7%), and ASDH plus small multiple contusions in 4 (14.3%) patients. Dura was left open in all the cases. The preoperative mean GCS was 8.39 ± 3.01. A total of 8 (28.6%) patients expired during the first postoperative week. The mean GCS of the remaining 20 patients at discharge was 10.55 ± 4.05. At 3 months follow-up, 7 (25%) patients were in vegetative state (GOS2), 3 (10.7%) were having major disability (GOS3) and 10 (35.7%) had good (GOS 4 and 5) clinical outcome.
Conclusion: The decompressive craniectomy can be very helpful in patients of traumatic brain injury because it can lower the ICP and improve the survival rate in TBI patients.
Abbreviations: GCS (Glasgow Coma Scale), GOS (Glasgow Outcome Scale), ICP (Intracranial Pressure)
Incidence and Management Outcome of Incidental Durotomy in Spinal Procedures in Tertiary Care Hospital
Get PDFObjective: To know the incidence and management outcome of incidental durotomy in spinal procedures in tertiary care hospital.
Materials and Methods: This descriptive study was carried out in Neurosurgery Department, Hayatabad Medical Complex, Peshawar, from 1st July 2015 to 30 June 2017. All those patients in whom lumber spinal procedures were done were included in the study without age or gender discrimination. Exclusion criteria included patients in whom dura was intentionally opened as in cases of intradural tumors or in rare cases of transdural discectomies. Those patients were also excluded in whom procedure was done elsewhere and they were admitted in ward for management. All patients were reviewed by age, sex, indications of surgery and subsequent management of durotomy. Data was analyzed in SPSS version 10.
Results: Total 560 patients qualified the selection criteria. There were 342 (61.07) male and 318 (38.93%) female patients. Amongst those operated, 294 (52.5%) patients had lumbar disc herniations, 143 (25.54%) patients were operated for lumbar spinal stenosis, 75 (13.39%) patients were treated for traumatic lumbar vertebral fractures, 38 (6.79%) patients had extradural spinal tumors and 10 were operated for lumbar spondylolisthesis. We noticed incidental durotomies in 50 (8.92%) cases. Of 342 male patients the incidence of durotomy was 20 (3.57%) while of 318 female patients the incidence was 30 (5.36%). All dural tears were recognized during the operation. Forty seven (47) dural tears were repaired primarily. We did re exploration in one patient for persistent leak in whom dural stitches were torn. Kerrisonrongeur was responsible for dural tear in 14. In 11 cases dissector tear the dura. Three dural tears were caused by pituatery rongeur. One tear was caused directly by knife. Air drill was responsible for 4 tears when lamina was being drilled to thin out. We could not find any cause of dural tear in one case.
Conclusion: Unintentional duratomy is not an uncommon complication in neuro spinal procedures. This is more common female population and elderly patients with degenerative spinal diseases