RESUMO
Neurocysticercosis (NCC), a major cause of global acquired epilepsy, results from Taenia solium larval brain infection. T. solium adult worms release large numbers of infective eggs into the environment contributing to high levels of exposure in endemic areas. This study identifies T. solium proteins in the sera of individuals with and without NCC using mass spectrometry to examine exposure in endemic regions. Forty-seven patients (18-51 years), 24 parenchymal NCC (pNCC), 8 epilepsy of unknown aetiology, 7 glioma, 8 brain tuberculoma, and 7 healthy volunteers were studied. Trypsin digested sera were subject to liquid chromatography-tandem mass spectrometry and spectra of 375-1700 m/z matched against T. solium WormBase ParaSite database with MaxQuant software to identify T. solium proteins. Three hundred and nineteen T. solium proteins were identified in 87.5% of pNCC and 56.6% of non-NCC subjects. Three hundred and four proteins were exclusive to pNCC sera, seven to non-NCC sera and eight in both. Ten percent, exhibiting immune-modulatory properties, originated from the oncosphere and cyst vesicular fluid. In conclusion, in endemic regions, T. solium proteins are detected in sera of individuals with and without pNCC. The immunomodulatory nature of these proteins may influence susceptibility and course of infection.
Assuntos
Proteínas de Helminto , Neurocisticercose , Taenia solium , Humanos , Neurocisticercose/sangue , Neurocisticercose/parasitologia , Taenia solium/imunologia , Adulto , Adolescente , Animais , Pessoa de Meia-Idade , Adulto Jovem , Masculino , Feminino , Proteínas de Helminto/sangue , Cromatografia Líquida , Espectrometria de Massas em Tandem , Espectrometria de Massas , Soro/químicaRESUMO
PURPOSE: The purpose of this study is to document the prevalence of MR findings suggestive of idiopathic intracranial hypertension (IIH) in patients undergoing endoscopic repair of spontaneous CSF rhinorrhea (SCSFR). METHODS: In a retrospective study, MR images of 117 consecutive patients who had undergone endoscopic repair of SCSFR were evaluated for features suggestive of IIH (empty sella, widened optic nerve sheath, tortuous optic nerve, flattened posterior globe, and enlarged Meckel's cave). Pituitary height was used to diagnose partial and complete empty sella. MR images were independently evaluated by two of the authors without knowledge of the clinical findings. Consensus method was used to resolve differences between the two evaluators. RESULTS: Empty or partially empty sella was diagnosed in the MR of 105 (89.7%) patients. In 38/105 (36.2%) patients with empty/partial empty sella, no additional MR findings were present. In 43/105 (41%) patients, one or more of the MR features with high specificity for diagnosis of IIH (flattened posterior globe and enlarged Meckel's cave) were seen. In the other 24 (22.9%) additional MR findings, less specific for IIH (widened optic nerve sheath, tortuous optic nerve) were noted. Papilledema was seen in 11 of 60 (18.3%) patients who underwent funduscopic examination. All patients with papilledema had empty/partial empty sella, and 9/11 (81.8%) had an additional MR finding suggestive of IIH. CONCLUSION: The majority of patients with SCSFR have MR imaging features of IIH. These imaging features should be a major component of previously published modified diagnostic criteria for IIH in patients with SCSFR.
Assuntos
Rinorreia de Líquido Cefalorraquidiano , Hipertensão Intracraniana , Papiledema , Pseudotumor Cerebral , Rinorreia de Líquido Cefalorraquidiano/diagnóstico por imagem , Humanos , Imageamento por Ressonância Magnética/métodos , Pseudotumor Cerebral/complicações , Pseudotumor Cerebral/diagnóstico por imagem , Estudos RetrospectivosRESUMO
PURPOSE: To characterize the temporal profile of pre-operative deterioration in children with lipomyelomeningocele (LMMC) including those with congenital deficits and identify risk factors for clinical worsening. METHODS: Records of 87 children who underwent surgery for LMMC were retrospectively reviewed to study the temporal profile of pre-operative deterioration, defined by the onset of new neurological dysfunction or progression of a pre-existing deficit. Preoperative magnetic resonance imaging (MRI) studies were examined to identify radiological features associated with deterioration. In children with extra-spinal placodes, the angle subtended by the terminal placode with the cord at the level of the laminar-fascial defect ("J sign") was assessed. RESULTS: Pre-operative deterioration in function was seen in 37 children (43%), occurring at a median age of 36 months and was more frequent in children without congenital deficits (54% versus 27%; p = 0.016). On Cox regression analysis, extra-spinal location of the placode (p = 0.003) and presence of a congenital deficit (p = 0.009) were positively and negatively associated with deterioration respectively. On Kaplan-Meier analysis, the median deterioration-free survival time was 72 months and was positively associated with presence of congenital deficit (p = 0.026) and negatively associated with presence of an extra-spinal placode (p < 0.001) or a meningocele sac (p = 0.001). CONCLUSION: Extra-spinal location of the neural placode was associated with higher risk of clinical deterioration in children with LMMC, whereas the presence of a congenital deficit conferred a decreased risk. Risk stratification based on clinical and radiological features can be used to guide decisions regarding early prophylactic surgery in children with LMMC.
Assuntos
Lipoma , Meningomielocele , Neoplasias da Medula Espinal , Criança , Pré-Escolar , Humanos , Lipoma/cirurgia , Meningomielocele/complicações , Meningomielocele/diagnóstico por imagem , Meningomielocele/cirurgia , Estudos Retrospectivos , Fatores de Risco , Neoplasias da Medula Espinal/cirurgia , Resultado do TratamentoRESUMO
AIM: Patients with Chiari I malformations (CM1) have posterior fossa hypoplasia with crowding of the neural structures. We aimed to study the posterior fossa measurements to analyse the posterior fossa morphology, presence of basilar invagination (BI) and correlated the measurements with the degree of tonsillar descent. METHODS: We retrospectively reviewed data in170 patients who underwent foramen magnum decompression (FMD) for CM1. The posterior fossa measurements were compared with 30 controls. Patients were divided into those with and without BI. The variables measured included clival length, posterior fossa height, supraocciput length, posterior fossa diameter, foramen magnum width, Boogard's angle, clival angle, clival slope and the newly introduced foramen magnum (FM) angle. RESULTS: The average clivus length and posterior fossa height were significantly shorter with a significant increase in the Boogard's and FM angle in the patient groups. Tonsillar descent showed a negative correlation with posterior fossa height (r = -0.498, p ≤ 0.001) and clivus length (r = -0.325, p ≤ 0.001) and a positive correlation with Boogard's angle (r = 0.469, p ≤ 0.001) and FM angle (r = 0.330, p ≤ 0.001). Patients with BI had statistically significant reduced posterior fossa height (p ≤ 0.001) and increased extent of tonsillar herniation (p = 0.001) compared to patients without BI. CONCLUSION: Patients with CM1 have significantly shorter clival length and posterior fossa height with smaller posterior fossa in support of published data. The presence of BI shortens the posterior fossa height and worsens the extent of tonsillar herniation. An increased Boogard's angle and FM angle result in a more horizontally placed suboccipital bone compared to a slanting bone in normal persons.
Assuntos
Malformação de Arnold-Chiari , Encefalocele , Humanos , Adulto , Criança , Estudos Retrospectivos , Encefalocele/diagnóstico por imagem , Encefalocele/cirurgia , Imageamento por Ressonância Magnética , Malformação de Arnold-Chiari/diagnóstico por imagem , Malformação de Arnold-Chiari/cirurgia , Forame Magno/diagnóstico por imagem , Forame Magno/cirurgia , Fossa Craniana Posterior/diagnóstico por imagem , Fossa Craniana Posterior/cirurgiaRESUMO
PURPOSE: The purpose of this study is to evaluate the role of spinal angiography and arterial embolization in avoiding spinal cord ischemia in patients undergoing CT-guided alcohol injection of aggressive vertebral hemangiomas. METHODS: In this retrospective study, patients with vertebral hemangioma who underwent CT-guided direct alcohol injection between January 2007 and October 2018 were identified. Of 28 such patients, 26 had neurological deficits, and 2 had only back pain or radiculopathy. Direct alcohol injection without prior arterial embolization was done in 17 patients. Direct alcohol injection with prior arterial embolization was done in 11 patients. Clinical outcome was assessed immediately after the intervention and at follow-up. RESULTS: Three patients, who underwent alcohol injection without trans-arterial embolization, had worsening of neurological deficits in the post procedure period due to spinal cord ischemia. No complications related to spinal cord ischemia were noted in the embolization group. There was no significant difference in the outcomes between the two groups if the three patients with complications are excluded (p = 0.34). CONCLUSION: While CT-guided direct alcohol injection is effective in the management of symptomatic and aggressive vertebral hemangiomas, spinal angiography and trans-arterial embolization of the blood supply to the vertebral body hemangioma, prior to the direct transpedicular alcohol embolization of the lesion, improves the safety of the procedure.
Assuntos
Embolização Terapêutica , Hemangioma , Neoplasias da Coluna Vertebral , Angiografia , Descompressão Cirúrgica , Hemangioma/cirurgia , Hemangioma/terapia , Humanos , Estudos Retrospectivos , Neoplasias da Coluna Vertebral/cirurgia , Neoplasias da Coluna Vertebral/terapia , Tomografia Computadorizada por Raios XRESUMO
OBJECTIVE: This study documents the monitorability using different anesthesia regimes and accuracy of muscle motor evoked potentials (mMEPs) in children ≤2 years of age undergoing tethered cord surgery (TCS). METHODS: Intraoperative mMEP monitoring was attempted in 100 consecutive children, ≤2 years of age, undergoing TCS. MEP monitoring was done under 4 different anesthetic regimes: (Total intravenous anesthesia (TIVA); balanced anesthesia with sevoflurane and ketamine; balanced anesthesia with isoflurane and ketamine; and balanced anesthesia with sevoflurane). Factors analyzed for their effect on monitorability were: age, neurological deficits, type of anesthesia, and the number of pulses used for stimulation. RESULTS: Baseline mMEPs were obtained in 87% children. Monitorability of mMEPs was similar in children ≤1 year and 1-2 years of age (85.7% and 87.5%). In multivariate analysis, anesthesia regime was the only significant factor predicting presence of baseline mMEPs. Children undergoing TIVA (p=0.02) or balanced anesthesia with a combination of propofol, sevoflurane, and ketamine (p=0.05) were most likely to have baseline mMEPs. mMEPs had a sensitivity of 97.4%, specificity of 96.4%, negative predictive value of 98.2% and accuracy of 96.8%. CONCLUSIONS: Baseline mMEPs were obtained in >85% of children ≤2 years of age including those who had motor deficits. TIVA and balanced anesthesia with sevoflurane and ketamine are ideal for mMEP monitoring. mMEPs have a high accuracy although, false positive and false negative results can occasionally be experienced.
Assuntos
Potencial Evocado Motor , Propofol , Anestesia Geral , Criança , Estudos de Viabilidade , Humanos , Monitorização IntraoperatóriaRESUMO
AIM: To determine the functional outcomes and risk factors for outcomes following surgery for lipomyelomeningocele (LMMC). METHODS: Data from 109 children with LMMC who underwent surgery from January 2008 to December 2017 were retrospectively studied to evaluate functional outcomes and possible risk factors for early- (at discharge from hospital or within 1 month of surgery) and long-term outcomes after surgery. RESULTS: There were 53 boys and 56 girls with median age of 36 months (IQR 12-90 months; range, 4 months to 18 years) at surgery. At presentation, neurological function was normal (asymptomatic group) in 28 (25.7%) children while there was neurological dysfunction (symptomatic group) in 81 (74.3%). Near total or radical excision of lipoma was done in 71 (65.1%) children. Six (5.8%) children had deterioration of neurological function in the post-operative period with recovery of function in three of them. There were no statistically significant risk factors for early outcomes. At a mean follow-up of 62.5 months (IQR 35-82 months; range, 12-146 months), 21 (27.6%) of the 76 symptomatic group children (including 59.3% with incomplete bladder dysfunction) showed improvement, 52 (68.4%) remained the same, while 3 (4%) deteriorated. In 31 children (symptomatic group) who developed symptoms after 1 year of age, early surgery after development of symptoms was associated with better chances of recovery (p = 0.0008). In the asymptomatic group, 23 (88.5%) had normal neurological function at mean follow-up of 57.5 months (IQR 30-77 months; range, 12-141 months) and 3 (11.5%) had neurological deterioration. The mean time to late deterioration (re-tethering) from surgery was 51.3 months (IQR 24-75 months; range, 24-84 months). Presence of syrinx on initial MRI (p = 0.008) and partial resection of the lipoma (p = 0.02) were independent risk factors for delayed deterioration. CONCLUSION: Radical resection of LMMC probably helps in preserving neurological function in > 90% of children at long-term follow-up. Fifty-five percent of children > 2 years of age with incomplete bladder dysfunction regained normal function following surgery. In children who develop symptoms after birth, early surgical intervention can reverse the neurological deficits.
Assuntos
Lipoma , Meningomielocele , Neoplasias da Medula Espinal , Criança , Feminino , Humanos , Lactente , Lipoma/diagnóstico por imagem , Lipoma/cirurgia , Masculino , Meningomielocele/complicações , Meningomielocele/cirurgia , Estudos Retrospectivos , Resultado do TratamentoRESUMO
BACKGROUND: Sagittal alignment of the cervical spine might influence the development of radiological adjacent segment pathology (RASP) after central corpectomy (CC). Range of motion (ROM) of the adjacent segments is closely linked to the development of RASP. METHODS: To investigate the ROM of the adjacent segments after CC, we developed a C2-T1 finite element (FE) model. The model with a lordotic sagittal alignment served as the baseline model. Models with straight and kyphotic alignment were generated using mesh morphing methods. Single-level corpectomy at C5 was done on these models. Segmental ROMs of intact and corpectomized spines were compared for physiologic flexion-extension loads. RESULTS: The flexion ROM decreased by an average of 13% with the change in sagittal alignment from lordosis to kyphosis; however, a consistent decrease was not observed in extension. After CC, the ROM increased by an average of 95% and 31% in the superior and inferior adjacent segments. With kyphotic change in the sagittal alignment, the postoperative increase in flexion ROM exhibited a decreasing trend, while this was not seen in extension. CONCLUSIONS: Kyphotic changes of the intact spine resulted in segmental stiffening, and after corpectomy, it resulted in inconsistent variations of segmental extension ROMs.
Assuntos
Vértebras Cervicais/cirurgia , Cifose/diagnóstico por imagem , Lordose/diagnóstico por imagem , Complicações Pós-Operatórias/diagnóstico por imagem , Radiografia/métodos , Amplitude de Movimento Articular , Adulto , Vértebras Cervicais/diagnóstico por imagem , Feminino , Análise de Elementos Finitos , Humanos , MasculinoRESUMO
OBJECTIVE: To analyze factors associated with the development of early symptomatic hydrocephalus following posterior fossa tumor (PFT) surgery in children. METHODS: In this retrospective study, data from 148 children (age < 18 years) who underwent primary resection of their PFTs without preoperative permanent CSF diversion procedures were collected. The incidence of symptomatic hydrocephalus within 30 days of tumor resection was studied and its association with various demographic, tumor-related, and surgery-related risk factors was analyzed. RESULTS: At presentation, 131 (89%) of the 148 patients had symptomatic hydrocephalus. There were 99 males and 49 females (mean age 8.7 years; range 1 to 17 years). Postoperatively, 14 (9.4%) patients required shunt placement for symptomatic hydrocephalus. The indications for shunt surgery were persistent symptoms of raised intracranial pressure (n = 6, 43%), CSF leak from the wound (n = 7, 50%), and tense pseudomeningocele (n = 1, 7%). On multivariate analysis, age < 6 years (OR 5.9, 95% CI 1.6-22.6, p = 0.009) and the presence of intraventricular blood (IVB) on postoperative CT (OR 6.4, 95% CI 1.7-23.7, p = 0.006) were independent risk factors for developing symptomatic hydrocephalus. CONCLUSIONS: The incidence of postoperative symptomatic hydrocephalus in our series (9.4%) is lower than that reported in most previous studies. Age < 6 years and the presence of postoperative IVB were independent risk factors for developing symptomatic hydrocephalus. Of these, postoperative IVB is probably the only modifiable risk factor.
Assuntos
Craniotomia/efeitos adversos , Hidrocefalia/etiologia , Neoplasias Infratentoriais/cirurgia , Derivação Ventriculoperitoneal , Adolescente , Criança , Pré-Escolar , Feminino , Humanos , Hidrocefalia/cirurgia , Lactente , Masculino , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/cirurgia , Período Pós-Operatório , Estudos Retrospectivos , Fatores de RiscoRESUMO
Objective: To evaluate the safety and efficacy of long tunnelled external ventricular drains (LTEVD) as a temporizing measure in patients with ventriculitis/meningitis requiring cerebrospinal fluid (CSF) diversion in whom immediate shunt surgery is not feasible.Methods: A retrospective review of the records of 15 patients with ventriculitis/meningitis, in whom an LTEVD was inserted, was performed to evaluate its safety, new onset CSF infection and need for permanent CSF diversion.Results: 15 patients with ventriculitis/meningitis had 16 LTEVDs placed between May 2006 and December 2016. There were 10 males and 5 females, their mean age being 16.5 years (range, 8 months-50 years). The mean duration of CSF drainage was 15.6 days (range, 4 to 44 days). Of the 16 LTEVDs that were inserted, two (13.3% - one CSF infection and one wound infection) developed new infection after 44 and 17 days of continuous CSF drainage respectively. The LTEVDs were removed and permanent CSF diversion procedures were performed in 10 patients during the same admission and in one patient later. At a mean follow up of 11.6 months (range 2-40 months), 8 of the 11 patients who underwent a permanent CSF diversion procedure had no clinical features of meningitis/ventriculitis.Conclusion: LTEVDs are an effective method of temporary CSF diversion in patients requiring the same for more than 5 days. These drains have a low infection rate when placed up to four weeks making them a safe and efficacious adjunct in management of ventriculitis/meningitis associated hydrocephalus.
Assuntos
Infecções do Sistema Nervoso Central/complicações , Infecções do Sistema Nervoso Central/cirurgia , Ventrículos Cerebrais/cirurgia , Drenagem/instrumentação , Drenagem/métodos , Hidrocefalia/etiologia , Hidrocefalia/cirurgia , Adolescente , Adulto , Ventriculite Cerebral/cirurgia , Líquido Cefalorraquidiano , Pré-Escolar , Drenagem/efeitos adversos , Feminino , Seguimentos , Humanos , Lactente , Estudos Longitudinais , Masculino , Meningite/cirurgia , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/terapia , Estudos Retrospectivos , Resultado do TratamentoRESUMO
Neurocysticercosis is associated with epilepsy in pig-raising communities with poor sanitation. Current internationally recognized diagnostic guidelines for neurocysticercosis rely on brain imaging, a technology that is frequently not available or not accessible in areas endemic for neurocysticercosis. Minimally invasive and low-cost aids for diagnosing neurocysticercosis epilepsy could improve treatment of neurocysticercosis. The goal of this study was to test the extent to which patients with neurocysticercosis epilepsy, epilepsy of unknown etiology, idiopathic headaches and among different types of neurocysticercosis lesions could be distinguished from each other based on serum mass profiling. For this, we collected sera from patients with neurocysticercosis-associated epilepsy, epilepsy of unknown etiology, recovered neurocysticercosis, and idiopathic headaches then performed binary group comparisons among them using electrospray ionization mass spectrometry. A leave one [serum sample] out cross validation procedure was employed to analyze spectral data. Sera from neurocysticercosis patients was distinguished from epilepsy of unknown etiology patients with a p-value of 10-28. This distinction was lost when samples were randomized to either group (p-valueâ¯=â¯0.22). Similarly, binary comparisons of patients with neurocysticercosis who has different types of lesions showed that different forms of this disease were also distinguishable from one another. These results suggest neurocysticercosis epilepsy can be distinguished from epilepsy of unknown etiology based on biomolecular differences in sera detected by mass profiling.
Assuntos
Epilepsia/diagnóstico , Neurocisticercose/diagnóstico , Adolescente , Adulto , Animais , Edema Encefálico/complicações , Diagnóstico Diferencial , Epilepsia/sangue , Feminino , Humanos , Índia , Masculino , Pessoa de Meia-Idade , Neurocisticercose/sangue , Neurocisticercose/complicações , Sensibilidade e Especificidade , Espectrometria de Massas por Ionização por Electrospray , Suínos , Doenças dos Suínos/parasitologia , Doenças dos Suínos/transmissão , Cefaleia do Tipo Tensional/sangue , Cefaleia do Tipo Tensional/diagnóstico , Adulto JovemRESUMO
PURPOSE: The purpose of this study was to assess the prevalence of FFT as an additional tethering element in children operated for closed spinal dysraphism, where FFT was not the primary tethering pathology. METHODS: This is a retrospective study of 195 children (< 18 years of age) who underwent surgery for closed spinal dysraphism and did not have FFT as the primary diagnosis. All patients were operated during the period 2005-2017 by a single surgeon. The commonest diagnosis was a lipomyelomeningocele (LMMC, n = 81, 41.5%), followed by split cord malformations (SCM, types I and II, n = 61, 31.3%), dermal sinus (n = 28, 14.4%), and dermoid cyst (n = 10, 5.1%). Factors such as age and sex, presenting symptoms, intraoperative findings, and radiological presence of a FFT on a magnetic resonance imaging (MRI) were documented, and the relationship between the primary diagnoses and presence of FFT was analyzed. RESULTS: FFT as a secondary finding was seen in 63 patients (32.3%). The mean age of the cohort was 54 months (4.5 years) and the sex distribution was relatively even (51.8% girls). The commonest symptom at presentation was a swelling in the back, followed by lower limb weakness. The mean duration of symptoms was nearly 30 months. FFT was seen on the MRI and confirmed intraoperatively in 55 patients (28.2%). There were 8 patients (4.1%) where a FFT was seen intraoperatively, but was not diagnosed on the preoperative MRI. In 16 patients, FFT was seen > 2 segments away from the primary tethering pathology, 8 of which mandated a second skin incision for sectioning of the FFT. Secondary FFT was most commonly associated with a SCM (types I and II combined) and was seen in 42.6% of those patients. It was least commonly associated with intradural dermoid cysts. CONCLUSION: The presence of a secondary FFT should be considered and actively sought on preoperative thin-slice T1W axial MR images in the sacral region in all patients with spinal dysraphism. Even if a FFT is not seen on preoperative MR images, the filum should be explored and sectioned if it is in the vicinity of the primary surgical field, especially in patients with SCM.
Assuntos
Cauda Equina/anormalidades , Cauda Equina/patologia , Lipoma/complicações , Lipoma/cirurgia , Defeitos do Tubo Neural/complicações , Disrafismo Espinal/cirurgia , Adolescente , Cauda Equina/cirurgia , Criança , Pré-Escolar , Estudos de Coortes , Feminino , Humanos , Processamento de Imagem Assistida por Computador , Lactente , Lipoma/diagnóstico por imagem , Imageamento por Ressonância Magnética , Masculino , Meningomielocele , Microcirurgia , Radiologia , Disrafismo Espinal/complicaçõesRESUMO
BACKGROUND: Neurocysticercosis (NCC) is an infestation of the nervous system caused by encysted larvae of Taenia solium. NCC is an important acquired cause of epilepsy and other neurological manifestations especially in endemic areas. NCC in children has pleomorphic manifestations depending on the location, number, viability of the cysts, and host response. Even with advancing knowledge of the disease manifestations, many aspects related to diagnosis and treatment, particularly in children, still remain controversial and pose challenges to clinical practice. There is no gold standard test to diagnose NCC and the management recommendations are still emerging. This review provides an overview of diagnosis of NCC in children and its management with special focus on current challenges and future prospects. DISCUSSION: In developing countries, NCC is important not only because of its frequency but also because of high morbidity and mortality rates associated, especially in cases in which it progresses to increased intracranial pressure. Because of its pleomorphic presentation, NCC should be considered in the differential diagnosis of a number of neurological conditions. Treatment with cysticidal therapy leads to reduction in seizure frequency and a faster resolution of lesions. CONCLUSIONS: We have summarized the current approaches to diagnosis and treatment of NCC, recent advances in understanding the biology of NCC, and how one can take advantage of these new insights to formulate the next generation of clinical trials.
Assuntos
Encefalopatias/diagnóstico , Encefalopatias/etiologia , Encefalopatias/terapia , Neurocisticercose/diagnóstico , Neurocisticercose/terapia , Criança , Feminino , Humanos , MasculinoRESUMO
The objective of this paper was to evaluate whether available evidence supporting placement of subdural drain placement after evacuation of chronic subdural haematoma (CSDH) is applicable to a cohort of patients managed by us. In this observational cohort study, clinical follow-up was obtained in 166 patients who underwent burr hole evacuation of CSDH without placement of subdural drain followed by 3 days of bed rest. The primary outcome studied was recurrence requiring reoperation. Factors predicting recurrence were also analysed. We compared the patient characteristics and management protocols in our cohort with that in reports supporting drain placement to determine whether such evidence is relevant to our patient group. The mean age of our patients was 58 ± 17 years (range, 1 to 89 years). Sixteen of the 166 (9.6%) patients presented with symptomatic recurrence. The median time to reoperation for recurrence (15 of 16 patients) after the primary procedure was 17 days (range, 2 to 68 days). Antiplatelet and anticoagulant therapy was the only factor that was significantly associated with recurrence (p = 0.01). There were no infective or non-infective complications in our patient cohort. Our patient cohort and outcomes differed from those reporting drain placements in the following parameters: they were a decade younger, all patients received bed rest for 3 days after surgery and the recurrence rate was similar to that reported in the drained groups but significantly less than that reported in the non-drained groups. Routine placement of drain following burr hole evacuation of CSDH should only be done after careful comparison of the patient cohort under consideration and those reporting superior outcomes with drains. Evidence-based medicine supports such an approach.
Assuntos
Drenagem , Hematoma Subdural Agudo/cirurgia , Hematoma Subdural Crônico/cirurgia , Trepanação , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Pré-Escolar , Estudos de Coortes , Feminino , Humanos , Lactente , Masculino , Pessoa de Meia-Idade , Recidiva , Reoperação , Resultado do Tratamento , Adulto JovemRESUMO
BACKGROUND: There are sparse data on the recovery of sympathetic skin response (SSR) following decompressive surgery in patients with cervical spondylotic myelopathy (CSM). We designed a study to assess SSR in patients with moderate and severe (Nurick grades 3, 4 and 5) CSM, and its recovery following central corpectomy (CC). METHOD: We conducted a prospective study on 19 patients with moderate and severe CSM who underwent CC from June 2008 to December 2010. Autonomic dysfunction was defined as the presence of 'bladder dysfunction' or 'orthostatic hypotension'. All patients underwent SSR test preoperatively and at follow-up. Functional evaluation was done using Nurick grade and modified Japanese Orthopedic Association (mJOA) score preoperatively and at follow-up. FINDINGS: In the preoperative assessment, 14 of 19 (73.7%) patients had bladder dysfunction and orthostatic hypotension. SSR was absent in 13 (68.4%) patients preoperatively. At a mean follow-up of 14.5 months after CC, SSR was present in 12 of the 14 patients available for follow-up. SSR returned postoperatively in 9 of the 11 patients in whom it was absent preoperatively. Recovery of SSR postoperatively had significant correlation with improvement in Nurick grade (p =0.02), improvement in lower limb component of mJOA score (p =0.001) and Nurick grade recovery rate (p = 0.008). CONCLUSIONS: Dysfunction of the autonomic pathways as determined by the SSR is seen in nearly 70% of patients with moderate and severe CSM but did not correlate with other autonomic functions, suggesting possibly different pathways for different autonomic functions. Following uninstrumented CC, SSR returned in almost 80% of patients in whom it was absent preoperatively and this correlated significantly with improvement in functional grade. Decompressive surgery can reverse autonomic dysfunction in most of these patients.
Assuntos
Doenças do Sistema Nervoso Autônomo/fisiopatologia , Descompressão Cirúrgica/métodos , Procedimentos Neurocirúrgicos/métodos , Pele/fisiopatologia , Espondilose/fisiopatologia , Espondilose/cirurgia , Sistema Nervoso Simpático/fisiopatologia , Adulto , Doenças do Sistema Nervoso Autônomo/etiologia , Feminino , Seguimentos , Humanos , Hipotensão Ortostática/etiologia , Hipotensão Ortostática/fisiopatologia , Extremidade Inferior/fisiopatologia , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Pele/inervação , Resultado do Tratamento , Bexiga Urinaria Neurogênica/etiologia , Bexiga Urinaria Neurogênica/fisiopatologiaRESUMO
OBJECTIVES: To evaluate the hand function in healthy individuals and in patients with cervical spondylotic myelopathy (CSM) undergoing central corpectomy using the nine-hole peg test (NHPT). MATERIALS AND METHODS: The NHPT was performed in healthy adults and in patients with CSM; overall, five trials were performed in the right and left hand separately. The preoperative and follow up NHPT score was compared to the normal and correlated with Nurick and modified Japanese Orthopedic Association (mJOA) scales. RESULTS: The NHPT score was significantly less in adult healthy female compared to adult healthy male subjects (difference, 0.71 s, P < 0.002). The distribution of the NHPT scores in normal adults followed the normal binomial distribution. The time taken to perform the NHPT with the right hand was significantly lower than the time taken to perform the NHPT with the left hand in both the sexes (P < 0.001). Thirty-six of the 47 patients with CSM (76.6%) had a prolonged preoperative NHPT score. There was a strong negative correlation between the preoperative NHPT score and the preoperative upper limb component of the modified-Japanese Orthopedic Association (UlmJOA) score. No significant change was detected in the NHPT score at one week postoperatively. On follow-up at six months or more (n = 21), the NHPT score normalized in five (35.7%) of the 14 patients in whom it was prolonged preoperatively. The NHPT score remained the same as the preoperative status in the other 16 patients, 7 of whom had a normal score preoperatively. The change in the NHPT score at follow-up did not correlate with the change in the UlmJOA score. CONCLUSIONS: Normative data among the Indian population suggest that female subjects have significantly lower scores than the male ones, and that there is a difference between the two sides that needs to be considered while reporting the NHPT scores in disease. The NHPT scores were prolonged preoperatively in CSM and showed a correlation with the UlmJOA score, and there was no significant change noted at one week follow-up. While the NHPT score is a good quantitative test to evaluate hand function in patients with CSM and could detect subtle hand dysfunction preoperatively, it has a limited role, when used alone, to detect changes in hand function postoperatively.
Assuntos
Atividade Motora/fisiologia , Exame Neurológico/métodos , Complicações Pós-Operatórias/diagnóstico , Caracteres Sexuais , Espondilose/cirurgia , Adulto , Descompressão Cirúrgica/efeitos adversos , Feminino , Mãos , Humanos , Masculino , Pessoa de Meia-Idade , Valores de Referência , Doenças da Medula Espinal/cirurgiaRESUMO
INTRODUCTION: The high success rate in the management medulloblastoma achieved in the western world is not exactly mirrored in developing countries including India. Socio-demographic differences, health-care disparity, and lack in uniformity of care with resultant widespread variations in the clinical practice are some of the reasons that may partly explain this difference in outcomes. Patients with medulloblastoma require a multi-disciplinary team approach involving but not limited to neuro-radiology, neurosurgery; neuropathology, molecular biology, radiation oncology, pediatric medical oncology and rehabilitative services for optimizing outcomes. METHODS: The Indian Society of Neuro-Oncology (ISNO) constituted an expert multi-disciplinary panel with adequate representation from all stakeholders to prepare national consensus guidelines for the contemporary management of medulloblastoma. RESULTS: Minimum desirable, as well as preferable though optional recommendations (as appropriate), were developed and adopted for the pre-surgical work-up including neuroimaging; neurosurgical management including surgical principles, techniques, and complications; neuropathology reporting and molecular testing; contemporary risk-stratification in the molecular era; appropriate adjuvant therapy (radiotherapy and chemotherapy); and follow-up schedule in medulloblastoma. CONCLUSIONS: The current document represents a broad consensus reached amongst various stakeholders within the neuro-oncology community involved in the contemporary curative-intent management of children with medulloblastoma. It provides both general as well as specific guidelines and recommendations to be adopted by physicians and health care providers across India to achieve uniformity of care, improve disease-related outcomes, and compare results between institutions within the country.
Assuntos
Neoplasias Cerebelares/terapia , Consenso , Oncologia , Meduloblastoma/terapia , Neurologia , Guias de Prática Clínica como Assunto , Sociedades Médicas , Neoplasias Cerebelares/diagnóstico , Humanos , Índia , Oncologia/normas , Meduloblastoma/diagnóstico , Neurologia/normas , Guias de Prática Clínica como Assunto/normas , Sociedades Médicas/normasRESUMO
Neurocysticercosis (NCC) is the most common single cause of seizures/epilepsy in India and several other endemic countries throughout the world. It is also the most common parasitic disease of the brain caused by the cestode Taenia solium or pork tapeworm. The diagnosis of NCC and the tapeworm carrier (taeniasis) can be relatively inaccessible and expensive for most of the patients. In spite of the introduction of several new immunological tests, neuroimaging remains the main diagnostic test for NCC. The treatment of NCC is also mired in controversy although, there is emerging evidence that albendazole (a cysticidal drug) may be beneficial for patients by reducing the number of seizures and hastening the resolution of live cysts. Currently, there are several diagnostic and management issues which remain unresolved. This review will highlight some of these issues.
Assuntos
Epilepsia/diagnóstico , Epilepsia/tratamento farmacológico , Neurocisticercose/diagnóstico , Neurocisticercose/tratamento farmacológico , Albendazol/uso terapêutico , Animais , Encéfalo/parasitologia , Encéfalo/fisiopatologia , Epilepsia/parasitologia , Humanos , Índia , Neurocisticercose/epidemiologia , Neurocisticercose/parasitologia , Carne Vermelha/parasitologia , Suínos/parasitologia , Taenia solium/patogenicidadeRESUMO
OBJECTIVE The goal of this study was to investigate the prevalence and risk factors of clinical adjacent-segment pathology (CASP) following central corpectomy for cervical spondylotic myelopathy (CSM) or ossification of the posterior longitudinal ligament (OPLL). METHODS The authors reviewed 353 cases involving patients operated on by a single surgeon with a minimum 12-month follow-up after central corpectomy for CSM or OPLL between 1995 and 2007. Patients with symptoms consistent with CASP at follow-up were selected for the study. The authors analyzed the prevalence and risk factors for CASP after central corpectomy for CSM/OPLL. RESULTS Fourteen patients (13 male, 1 female; mean age 46.9 ± 7.7 years) were diagnosed with symptoms of CASP (3.9% of 353 patients) at follow-up. The mean interval between the initial surgery and presentation with symptoms of CASP was 95.6 ± 54.1 months (range 40-213 months). Preoperative Nurick grades ranged from 2 to 5 (mean 3.5 ± 1.2), and the Nurick grades at follow-up ranged from 1 to 5 (mean 3.0 ± 1.3, p = 0.27). Twelve patients had myelopathic symptoms and 2 had radiculopathy at follow-up. Patients with poorer preoperative Nurick grades had a higher risk for development of CASP (HR 2.6 [95% CI 1.2-5.3], p = 0.01). CONCLUSIONS In the present study, CASP was seen in 3.9% of patients following central corpectomy for CSM/OPLL. The risk of CASP after central corpectomy for CSM/OPLL was higher in patients with poorer preoperative Nurick grades.
Assuntos
Descompressão Cirúrgica/efeitos adversos , Ossificação do Ligamento Longitudinal Posterior/cirurgia , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/patologia , Espondilose/cirurgia , Adulto , Vértebras Cervicais/diagnóstico por imagem , Vértebras Cervicais/cirurgia , Feminino , Humanos , Incidência , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Ossificação do Ligamento Longitudinal Posterior/diagnóstico por imagem , Complicações Pós-Operatórias/diagnóstico por imagem , Complicações Pós-Operatórias/etiologia , Modelos de Riscos Proporcionais , Radiculopatia/diagnóstico por imagem , Radiculopatia/epidemiologia , Radiculopatia/etiologia , Radiculopatia/cirurgia , Fatores de Risco , Espondilose/diagnóstico por imagem , Resultado do TratamentoRESUMO
OBJECTIVE This study was performed to describe the incidence and predictors of perioperative complications following central corpectomy (CC) in 468 consecutive patients with cervical spondylotic myelopathy (CSM) or ossification of the posterior longitudinal ligament (OPLL). METHODS The authors performed a retrospective review of a cohort of patients who had undergone surgery for CSM (n = 338) or OPLL (n = 130) performed by a single surgeon over a 15-year period. All patients underwent uninstrumented CC with autologous iliac crest or fibular strut grafting. Preoperative clinical and imaging details were collected, and the type and incidence of complications were studied. Univariate and multivariate analyses were performed to establish risk factors for the development of perioperative complications. RESULTS Overall, 12.4% of patients suffered at least 1 complication following CC. The incidence of major complications was as follows: C-5 radiculopathy, 1.3%; recurrent laryngeal nerve injury, 0.4%; dysphagia, 0.8%; surgical-site infection, 3.4%; and dural tear, 4.3%. There was 1 postoperative death (0.2%). On multivariate analysis, patients in whom the corpectomy involved the C-4 vertebral body (alone or as part of multilevel CC) were significantly more likely to suffer complications (p = 0.004). OPLL and skip corpectomy were risk factors for dural tear (p = 0.015 and p = 0.001, respectively). No factors were found to be significantly associated with postoperative C-5 palsy, dysphagia, or acute graft extrusion on univariate or multivariate analysis. Patients who underwent multilevel CC were predisposed to surgical-site infections, with a slight trend toward statistical significance (p = 0.094). The occurrence of a complication after surgery significantly increased the mean duration of postoperative hospital stay from 5.0 ± 2.3 days to 8.9 ± 6 days (p < 0.001). CONCLUSIONS Complications following CC for CSM or OPLL are infrequent, but they significantly prolong hospital stay. The most frequent complication following CC is dural tear, for which a diagnosis of OPLL and a skip corpectomy are significant risk factors.