Role of surgical modality and timing of surgery as clinical outcome predictors following acute subdural hematoma evacuation.

BACKGROUND & OBJECTIVE: A Craniotomy (CO) or decompressive craniectomy (DC) are the two main surgical procedures employed for evacuation of acute traumatic subdural hematoma (ASDH). However, the optimal surgical procedure remains controversial. The beneficial effect of early surgical evacuation of acute subdural hematoma in improving outcome also remains unclear. Our objective was to study the role of these two parameters in determining the outcome in patients undergoing surgical evacuation of acute traumatic subdural hematoma. METHODS: A retrospective analysis of 58 patients presenting with acute traumatic subdural hematoma and with presenting Glasgow Coma Scale (GCS) ≤ 8 that had been operated in Lahore General Hospital between June 2014 and July 2015 was performed. The demographic data, preoperative GCS, type of surgical procedure performed and timing of surgery were analysed. RESULTS: Forty (69%) patients underwent CO, and eighteen (31%) patients underwent DC. The CO and DC groups showed no difference in the demographic data and preoperative GCS. Six patients survived in the craniotomy group, while none survived in the decompressive craniectomy group (p=0.083). The relationship of timing of surgery with survival in the craniotomy group was found not to be clinically significant (p=0.87). CONCLUSION: In this study craniotomy was associated with a better outcome as compared to decompressive craniectomy, however, the difference did not reach statistical significance. Early surgery was also found not to be associated with an improved outcome.

Radiolological predictors of recurrence of chronic subdural hematoma.

OBJECTIVE: Chronic subdural hematoma is one of the most common clinical entities encountered in daily neurosurgical practice. Considerable recurrence rates have been reported for chronic subdural hematoma following surgical evacuation. Many studies have suggested various radiological factors that may be associated with the recurrence of CSDH. However, the results are inconsistent. This study focuses on determining the radiological factors predictive of chronic subdural hematoma recurrence. METHODS: A retrospective analysis of 113 patients diagnosed with chronic subdural hematoma who were surgically treated between August 2013 and December 2014 was performed. The radiological features were analyzed to clarify the correlation between these radiological factors and postoperative recurrence of chronic subdural hematoma. RESULTS: Twenty patients (17.7%) experienced recurrence. Chronic subdural hematoma recurrence was found to be significantly associated (p<0.05) with preoperative hematoma thickness ≥ 20 mm. Midline shift, hematoma density and bilaterality were not significantly associated with recurrence. Post operative drainage also significantly (p<0.05) reduced chronic subdural hematoma recurrence. CONCLUSION: Preoperative hematoma thickness ≥ 20 mm is an independent predictor of recurrence of chronic subdural hematoma. Postoperative drainage also significantly reduces chronic subdural hematoma recurrence.

Management of Cerebrospinal Fluid Leak following Posterior Cranial Fossa Surgery.

OBJECTIVE: Cerebrospinal fluid leakage remains a significant cause of morbidity following posterior fossa surgery, and its treatment remains a difficult problem. The aim of the study was to propose a treatment algorithm for its management. METHODS: A retrospective, single-center study was conducted on 147 patients who underwent elective posterior fossa surgery for a variety of diseases . Patients with post operative CSF leakage had either been treated initially with conservative measures including re-suturing of the wound, with CSF lumbar drainage to be employed in case the CSF leakage didn't stop, or the initial intervention was the institution of CSF lumbar drainage simultaneously with conservative measures. VP (ventriculo-peritoneal) shunt was done in patients with gross hydrocephalus on postoperative CT brain. RESULTS: There were 25 (17%) cases of CSF leakage, including 24 incisional CSF leaks and one case of CSF otorrhea. In eight patients with incisional CSF leakage treated initially with conservative measures including re-suturing of the wound, CSF leakage stopped in only two cases. CSF lumbar drainage instituted later on in six cases with persistent leakage stopped the CSF leakage. In fourteen patients managed initially with re-suturing of the wound and concomitant CSF lumbar drainage, CSF leakage settled in all the cases. Two patients with gross hydrocephalus on post operative CT were managed successfully with VP shunt. Re-suturing of the wound with concomitant CSF lumbar drainage was found to be significantly associated (p=0.003) with the stoppage of CSF leakage, and the settlement of meningitis (p= 0.014). CONCLUSION: Incisional CSF leaks after posterior fossa surgery should be managed with re-suturing of the wound and concomitant CSF lumbar drainage, instead of an initial trial of conservative therapy alone.

Aneurysmal Subarachnoid Hemorrhage: Outcome of Aneurysm Clipping Versus Coiling in Anterior Circulation Aneurysm.

OBJECTIVE: To compare the neurological outcome of microsurgical clipping versus coiling in patients with anterior circulation aneurysm. STUDY DESIGN: Comparative study. PLACE AND DURATION OF STUDY: Department of Neurosurgery, Lahore General Hospital, Lahore, from January 2010 to December 2013. METHODOLOGY: Patients aged 14 - 60 years, with ruptured cerebral aneurysm of anterior circulation and World Federation of Neurosurgical Society (WFNS) grades 1, 2 and 3 were included. Patients more than 60 years, medically unfit patient and posterior circulation aneurysms and WFNS grades 4 and 5 were excluded. Aneurysm sac obliteration was done in randomized manner with microsurgical clipping or coiling. Postoperatively, the patients were assessed and followed-up upto one year for outcome parameters on the bases of WFNS grade and Modified Ranking Scale (mRS) as favourable (mRS ≤2 ) and unfavourable (mRS > 2). RESULTS: Among 140 subjects selected for study, 70 were included in group A, i.e. coiling and other 70 were in group B, i.e. clipping. The median age of patients in group A was 52.5 ± 10 years and in group B was 51.00 ± 10 years. Overall, 56 (40%) males, 28 (60%) males in each group; and 84 (60%) females, 42 (60%) in each group were included. The male to female ratio in this study was 1:1.5. In group A, i.e. coiling, 27 (38.6%) patients had no disability (grades 1 and 2), 25 (35.7%) were slightly disabled (grade 3) and 18 (25.7%) had moderate disability (grade 4); whereas in group B, i.e. clipping group 23 (32.9%) patients had no disability (grades 1 and 2), 23 (32.9%) were slightly disabled (grade 3) and 24 (34.3%) had moderate disability (grade 4). At one year follow-up, in group A, favourable outcome was achieved in 56 (80%) of patients compared to 48 (68.6%) in group B; whilst, 14 (20%) patients in group Aand 22 (33.1%) in group B showed unfavourable outcome. Although mortality rate was higher in clipping (n=3, 4.3%) as compared to coiling (n=1, 1.4%), but was not statistically significant (p = 0.310). CONCLUSION: Endovascular coiling of anterior circulation aneurysms is safe and as effective and successful as aneurysm clipping and is less invasive also.

Surgical Outcome of Anterior Decompression, Grafting and Fixation in Caries of Dorsolumbar Spine.

OBJECTIVE: To evaluate the surgical outcome of anterior decompression, grafting and fixation in tuberculosis of the dorsal and lumbar spine with compression over the neural tissue and neural deficit. STUDY DESIGN: A case series. PLACE AND DURATION OF STUDY: Department of Neurosurgery Unit-I, Lahore General Hospital, Lahore, from January 2008 to March 2012. METHODOLOGY: Patients with caries spine having compression over the thecal sac with neurological deficit and kyphosis were included in the study. Patients below 17 years and above 56 years of age; those with bed sores and unfit for anesthesia were excluded from the study. Complete blood picture with ESR, X-rays of chest and of the relevant spinal level, and MRI were done. All patients were treated with corpectomy, debridement, drainage of abscess and grafting followed by fixation with poly-axial screws and rods. All patients were assessed by ASIA Impairment Scale before and after surgery and with Bridwell grading after surgery. RESULTS: Among 79 patients, 47 were males and 32 females. The mean age was 35.97 ± 8.8 years. The commonest level involved was the dorsolumbar junction (n=42, 53.16%). Lower limb power improved to ambulatory level in 60% of patients with complete paraplegia; recovery was excellent in patients with partial weakness; only 2 patients (2.53%) deteriorated to a lower grade. There was no postoperative mortality. One patient had long ICU stay due to lung injury. CONCLUSION: Corpectomy followed by grafting and fixation is safe and effective procedure for dorsolumbar spinal caries. Even those patients presenting with complete paraplegia showed improvement in motor power to ambulatory level and those who had partial deficit showed excellent improvement.

Chondroma of Cerebral Falx: A Rare Intracranial Diagnosis.

Chondromas are benign tumors which mostly occur in extremities but also sometimes in the cranium. Intracerebral chondroma is rare condition. Most intracranial chondromas arise from skull base, but chondroma of falx origin is a rare entity and mostly occurs in relation with syndromic disorders such as Mafucci's syndrome or Ollier's syndrome. Here, we report a rare case of falcine intracranial chondroma in a young man who presented with headaches and weakness of lower extremities and no signs of any syndromic disorder. The purpose of this case report was to raise awareness about intracranial chondromas. Chondroma should be considered in the differential diagnosis of calcified masses arising from the falx.

Hepatocellular carcinoma in a young man with resting and postural tremors.

A 25-year-old man who was normally fit and well, presented with a 2-year history of progressively worsening tremor. His tremor was generalised, affecting head, neck and all four limbs. One of the patient's brothers had suffered from similar problems, but never sought medical attention. Examination revealed a generalised tremor, of greater amplitude on the patient's left side, which increased in its amplitude upon exertion. Slit-lamp examination revealed bilateral Kayser-Fleischer rings and serum caeruloplasmin was found to be low, while 24 h urinary copper excretion was elevated. A diagnosis of Wilson's disease was made and an abdominal ultrasound was performed, revealing evidence of portal hypertension and a hyperechoic hepatic nodule, later confirmed to be hepatocellular carcinoma. The patient underwent partial hepatic resection and was started on D-penicillamine.

Aneurysmal subarachnoid haemorrhage: outcome of aneurysm clipping in elderly patients and predictors of unfavourable outcome.

OBJECTIVE: To determine the outcome of treatment of microsurgical clipping in elderly (60 - 70 years) patients with aneurysmal subarachnoid hemorrhage and determine the predictors of poor outcome. STUDY DESIGN: Longitudinal analytical study. PLACE AND DURATION OF STUDY: Nishtar Hospital, Multan, Mayo Hospital, Lahore, Department of Neurosurgery, Lahore General Hospital, Lahore, from January 2000 to January 2010. METHODOLOGY: Elderly patients (60 - 70 years) with ruptured cerebral aneurysm were enrolled and graded on the basis of World Federation of Neurosurgeons Scale (WFNS). Aneurysm sac obliteration was done in all the patients with microsurgical clipping. Postoperatively, the patients were assessed upto 3 months for outcome parameters i.e., neurological deterioration (based on WFNS grade and modified Rankin scale as favourable (mRS score ² 2) and unfavourable (mRS score > 2). The factors associated with unfavourable outcome were also noted which included age > 65 years, poor initial WFNS grade, and the occurrence of ischaemia. RESULTS: The mean age of the 48 patients was 65 + 5.45 years. There were 31 (64.6%) male and 17 (35.4%) female patients. Postprocedural neurological deterioration occurred in 23 patients (47.9%) related to ischaemia in 14 (29.16%), rebleeding in 1 (2%), and hydrocephalus in 8 (16.66%). At 03 months, the outcome was favourable in 25 patients (52.08%) and unfavourable in 23 (47.91%). CONCLUSION: In old patients, careful pre-operative assessment, interdisciplinary approach and meticulous tissue handling during aneurysm clipping may decrease the unfavourable outcome.