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There is a huge burden of patients suffering from trauma-induced disabling spasticity the world over. There are surprisingly few modalities of treatment with a sustained, proven benefit which can be offered to such patients. Selective dorsal rhizotomy (SDR) has been used with proven success in treating spasticity in patients of cerebral palsy, both in children and in adults. The rationale behind using the procedure in post-traumatic cases is reviewed, along with the cases reported till date in the world literature. The indications, surgical procedure used, outcome and complications, if any, are described. Most of the cases described in the literature have shown a favourable outcome with minimal complications. SDR can become an important tool in the armamentarium of the clinician treating this condition.
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Espasticidad Muscular/etiología , Espasticidad Muscular/cirugía , Procedimientos Neuroquirúrgicos/métodos , Rizotomía/métodos , Raíces Nerviosas Espinales/cirugía , Heridas y Lesiones/complicaciones , HumanosRESUMEN
Atypical teratoid/rhabdoid tumours (AT/RTs) are highly aggressive and uncommon malignant tumours of the central nervous system (CNS) affecting children younger than 3 years of age. Primary spinal cord involvement is an extremely rare presentation. AT/RTs show necrosis and haemorrhages on histopathology frequently. However, spinal atypical teratoid/rhabdoid tumour (AT/RT) with hematomyelia and spinal subarachnoid haemorrhage (SAH), as seen in our case, has never been reported in the literature in the paediatric age group. We report a case of primary spinal AT/RT in a 3-year-old male child presenting acutely with hematomyelia and spinal SAH and try to elucidate its pathophysiological basis.
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Neoplasias del Sistema Nervioso Central , Tumor Rabdoide , Enfermedades Vasculares de la Médula Espinal , Hemorragia Subaracnoidea , Teratoma , Preescolar , Humanos , Masculino , Tumor Rabdoide/complicaciones , Tumor Rabdoide/diagnóstico por imagen , Enfermedades Vasculares de la Médula Espinal/complicaciones , Enfermedades Vasculares de la Médula Espinal/diagnóstico por imagen , Hemorragia Subaracnoidea/diagnóstico por imagen , Hemorragia Subaracnoidea/etiología , Teratoma/complicaciones , Teratoma/diagnóstico por imagen , Teratoma/cirugíaRESUMEN
BACKGROUND: Focal cortical dysplasia (FCD) is a localized cortical malformation and considerable morphological overlap exists between FCD IIB and neurological lesions associated with Tuberous sclerosis complex (TSC). Abnormal mTOR pathway secondary to somatic mTOR mutation and TSC gene mutation linked to PI3K/AKT/mTOR pathway have supported the hypothesis of common pathogenesis involved. Role of converging pathway, viz. Wnt/ß-Catenin and mTOR is unknown in FCD. We aimed to analyse FCD IIB for TSC1/TSC2 mutations, immunoreactivity of hamartin, tuberin, mTOR and Wnt signalling cascades, and stem cell markers. MATERIALS AND METHODS: Sixteen FCD IIB cases were retrieved along with 16 FCD IIA cases for comparison. Immunohistochemistry was performed for tuberin, hamartin, mTOR pathway markers, markers of stem cell phenotype, and Wnt pathway markers. Mutation analysis for TSC1 and TSC2 was performed by sequencing in 9 FCD cases. RESULTS: All FCD cases showed preserved hamartin and tuberin immunoreactivity. Aberrant immunoreactivity of phospho-P70S6 kinase, S6 ribosomal, phospho-S6 ribosomal and Stat3 was noted in FCD IIB, with variable phospho-4E-BP1 (45%) and absent phospho-Stat3 expression. Immunoreactivity for phospho-P70S6 kinase (100%), S6 ribosomal protein (100%) and Stat3 (100%) was noted in FCD IIA, but not for phospho-S6 ribosomal, phospho-4E-BP1 and phospho-Stat3. c-Myc immunoreactivity was noted in all FCD cases. Nestin (81%) and Sox 2 (88%) stained balloon cells in FCD IIB (44%), while in FCD IIA cases were negative. All FCD cases were immunopositive for Wnt, but were negative for ß-Catenin and cyclin-D1. TSC mutations were detected in two cases of FCD IIB. CONCLUSION: Abnormal mTOR pathway activation exists in FCD IIB and IIA, however, shows differential immunoreactivity profile, indicating varying degrees of dysregulation. Labelling of neuronal stem cell markers in balloon cells suggests they are phenotypically immature. TSC1/2 mutation play role in the pathogenesis of FCD. Deep targeted sequencing is preferred diagnostic technique since conventional sanger sequencing often fails to detect low-allele frequency variants involved in mTOR/TSC pathway genes, commonly found in FCD.
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Epilepsia/metabolismo , Epilepsia/patología , Malformaciones del Desarrollo Cortical de Grupo I/metabolismo , Malformaciones del Desarrollo Cortical de Grupo I/patología , Transducción de Señal/fisiología , Serina-Treonina Quinasas TOR/metabolismo , Adolescente , Adulto , Niño , Preescolar , Femenino , Humanos , Lactante , Masculino , Adulto JovenRESUMEN
INTRODUCTION: Epilepsy has several comorbidities and associated stigma. Stigma associated with epilepsy is well known and prevalent worldwide. Surgical treatment is an established treatment for drug refractory epilepsy. Following surgery in children, it is possible that the stigma may reduce, but such an effect has not been studied earlier. MATERIALS AND METHODS: Analysis of prospectively collected data was performed for pediatric patients at a single tertiary center for treating epilepsy. Child stigma scale, as described by Austin et al., was used to evaluate stigma both pre- and postoperatively. Analysis was done using Paired t test. RESULTS: In this study, following surgery, there was significant reduction of stigma (P<0.001). This was proportional to the reduction in seizures, though there were 9 (30%) patients, who due to persistent neurodisability did not have any reduction of stigma despite having good seizure outcome. CONCLUSION: Surgery in drug-resistant epilepsy helps in reducing stigma. Seizure reduction is probably not the only factor responsible for a change in stigma outcome.
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Epilepsia Refractaria/cirugía , Calidad de Vida/psicología , Convulsiones , Estigma Social , Adolescente , Niño , Preescolar , Epilepsia Refractaria/psicología , Epilepsia/cirugía , Femenino , Humanos , Lactante , Masculino , Periodo Posoperatorio , Resultado del TratamientoRESUMEN
BACKGROUND: Gangliogliomas (GGs) are slow-growing glioneuronal tumors seen in children and young adults. They are associated with intractable epilepsy, and have recently been found to harbor BRAF (B- rapidly accelerated fibrosarcoma) gene mutations. However, the mammalian target of rapamycin (mTOR) signaling pathway, downstream of BRAF, has not been evaluated extensively in GGs. MATERIALS AND METHODS: GG cases were retrieved, clinical data obtained, and histopathological features reviewed. Sequencing for BRAF V600E mutation, analysis of BRAF copy number by quantitative real-time polymerase chain reaction, and immunohistochemistry for mTOR pathway markers p-S6 and p-4EBP1 were performed. RESULTS: Sixty-four cases of GG were identified (0.9% of central nervous system tumors). Of these, 28 had sufficient tumor tissue for further evaluation. Mixed glial and neuronal morphology was the commonest (64%) type. Focal cortical dysplasia was identified in the adjacent cortex (6 cases). BRAF V600E mutation was identified in 30% of GGs; BRAF copy number gain was observed in 50% of them. p-S6 and p-4EBP1 immunopositivity was seen in 57% cases each. Thus, mTOR pathway activation was seen in 81% cases, and was independent of BRAF alterations. 87% patients had Engel grade I outcome, while 13% had Engel grade II outcome. Both the Engel grade II cases analyzed showed BRAF V600E mutation. CONCLUSION: BRAF V600E mutation is frequent in GGs, as is BRAF gain; the former may serve as a target for personalized therapy in patients with residual tumors, necessitating its assessment in routine pathology reporting of these tumors. Evidence of mTOR pathway activation highlights similarities in the pathogenetic mechanisms underlying GG and focal cortical dysplasia, and suggests that mTOR inhibitors may be of utility in GG patients with persistent seizures after surgery.
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Neoplasias Encefálicas/genética , Neoplasias Encefálicas/metabolismo , Ganglioglioma/genética , Ganglioglioma/metabolismo , Proteínas Proto-Oncogénicas B-raf/genética , Serina-Treonina Quinasas TOR/metabolismo , Adolescente , Adulto , Niño , Femenino , Humanos , Masculino , Persona de Mediana Edad , Mutación , Estudios Retrospectivos , Transducción de Señal/fisiología , Adulto JovenRESUMEN
BACKGROUND: Subependymal giant cell astrocytomas (SEGA) are slow-growing benign intraventricular tumors, the pathogenesis of which is debated. Recent studies have shown that tuberous sclerosis complex (TSC) 1 and TSC2 genes are linked to the mammalian target of rapamycin (mTOR) cell signaling pathway. We aimed to analyze TSC1 and TSC2 gene mutation, hamartin and tuberin protein expression, and protein expression of mTOR signaling cascade in a series of SEGA to determine their role in pathogenesis. MATERIALS AND METHODS: Twenty-eight SEGA cases were retrieved from archival material. Immunohistochemistry was performed on formalin-fixed, paraffin-embedded tissue using antibodies against tuberin, hamartin, phospho-p70S6 kinase, S6 ribosomal protein, phospho-S6 ribosomal protein, phospho-4E-BP1, Stat3, and phospho-Stat3. Mutation analysis of TSC1 (exons 15 and 17) and TSC2 (exons 33, 39, and 40) was done by DNA sequencing. RESULTS: Loss of immunoexpression of either hamartin or tuberin was found in 19 cases (68%). Pathogenic point mutations in selected exons of TSC1 and TSC2 genes were present in 5 of 20 cases studied. Robust expression of mTOR downstream signaling molecules phospho-p70S6 kinase (100%), S6 ribosomal protein (82%), phospho-S6 ribosomal protein (64%), phospho-4E-BP1 (64%), and Stat3 (100%) was seen. Four cases (14%) showed immunopositivity for phospho-Stat3. There was no significant correlation of these markers with immunoloss of tuberin and hamartin. SIGNIFICANCE: There is a definite role for TSC1 and TSC2 genes in the pathogenesis of SEGA as evidenced by loss of protein expression and presence of mutations. Strong expression of mTOR downstream signaling proteins indicates activation of mTOR pathway in these tumors, suggesting that proteins in this pathway may have the potential to serve as therapeutic targets in these patients.
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Astrocitoma/genética , Transducción de Señal , Serina-Treonina Quinasas TOR/fisiología , Proteínas Supresoras de Tumor/fisiología , Proteínas Adaptadoras Transductoras de Señales , Astrocitoma/metabolismo , Proteínas de Ciclo Celular , Análisis Mutacional de ADN , Humanos , Inmunohistoquímica , Fosfoproteínas , Proteína S6 Ribosómica , Esclerosis Tuberosa , Proteína 1 del Complejo de la Esclerosis Tuberosa , Proteína 2 del Complejo de la Esclerosis TuberosaRESUMEN
PURPOSE: To determine the impact of intraoperative magnetic resonance imaging (iMRI) in epilepsy surgeries on the extent of surgical resection and seizure outcome along with its feasibility and limitations. METHODS: Patients with pharmacoresistant epilepsy (PRE), who underwent surgeries in operating theater equipped with high-field 1.5-Tesla MRI, were evaluated for extent of resection, operative time, scanning time, pathologies, resultant extra resection, and seizure outcomes. RESULTS: Thirty-nine patients with mean age of 18 (range: 3-65) years with PRE underwent surgical intervention. Mean duration of epilepsy was 10.2 years. Surgical interventions included tumor resection (31%), resection of focal cortical dysplasia (28%), mesial temporal lobe surgeries (18%), and disconnection surgeries (23%). iMRI alone, apart from navigation and electrophysiology, improved resection rates in 13% (5 out of 39) of these patients. In lesional group, iMRI modified operative strategy resulting in increased resections in 21% (5/23) patients. Complete resection was observed in 87% of patients. iMRI scanning time constituted 25% (mean: 72 ± 21 min) of time spent under anesthesia by the patient. Major and minor complications were observed in 2.5% and 7.5% of patients, respectively. The mean follow-up was 14 months. Favorable postoperative seizure control (Engel Classes I and II) was achieved in 85% and complete seizure freedom was achieved in 77% of patients (Engel Class IA) at 1-year follow-up. CONCLUSIONS: iMRI increases the extent of resection mainly in lesional epilepsy surgeries translating into good seizure outcomes but not found to be much beneficial in prototype mesial temporal sclerosis surgeries and disconnection surgeries.
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Lobectomía Temporal Anterior , Epilepsia/cirugía , Imagen por Resonancia Magnética , Lóbulo Temporal/cirugía , Adolescente , Adulto , Anciano , Lobectomía Temporal Anterior/métodos , Niño , Preescolar , Electroencefalografía/métodos , Femenino , Humanos , Lactante , Imagen por Resonancia Magnética/métodos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Resultado del Tratamiento , Adulto JovenRESUMEN
Bronchial asthma is an important public health problem in India with significant morbidity. Several international guidelines for diagnosis and management of asthma are available, however there is a need for country-specific guidelines due to vast differences in availability and affordability of health-care facilities across the globe. The Indian Chest Society (ICS) and the National College of Chest Physicians (NCCP) of India have collaborated to develop evidence-based guidelines with an aim to assist physicians at all levels of health-care in diagnosis and management of asthma in a scientific manner. Besides a systematic review of the literature, Indian studies were specifically analysed to arrive at simple and practical recommendations. The evidence is presented under these five headings: (1) definitions, epidemiology and impact, (2) diagnosis, (3) pharmacologic management of stable disease, (4) management of acute exacerbations, and (5) non-pharmacologic management and special situations. The modified grade system was used for classifying the quality of evidence as 1, 2, 3, or usual practice point (UPP). The strength of recommendation was graded as A or B depending upon the level of evidence.
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Asma/diagnóstico , Asma/terapia , Humanos , India , Sociedades MédicasRESUMEN
BACKGROUND: The use of minimally invasive endoscopic surgery is fast emerging in many subspecialties of neurosurgery as an effective alternative to the open procedures. OBJECTIVE: The author describe a novel technique of using an endoscope for performing a corpus callosotomy and hemispherotomy. A description of endoscopic disconnection for a hypothalamic hamartoma (HH) and a review of the literature is also presented. MATERIALS AND METHODS: Thirty four patients underwent endoscopic procedures between January 2010 and March 2015. These included endoscopic-assisted inter-hemispheric trans-callosal hemispherotomy (EH; n = 11), endoscopic-assisted corpus callosotomy with anterior/posterior commissurotomy (CCWC; n = 16), and endoscopic disconnection for HH (n = 7). EH and CCWC were performed with the use of a small craniotomy (4 cm × 3 cm). The surgeries were performed using a rigid high-definition endoscope, bayonetted self-irrigating bipolar forceps, and other standard endoscopic instruments along with the guidance of intra-operative magnetic resonance imaging and neuronavigation. HH disconnection was performed using endoscopic neuronavigation through a burr hole. RESULTS: Hemispherotomy: Sequelae of middle cerebral artery infarct (5), Rasmussen's syndrome (3), and hemimegalencephaly (3). OUTCOME: Class I Engel (9) and class II (2), mean follow-up of 8.4 months, range: 3-18 months. Mean blood loss: 85 cc, mean operating time: 210 min. CCWC: All had a diagnosis of Lennox-Gastaut syndrome (LGS), with etiologies of hypoxic insult (10), lissencephaly (2), bilateral band heterotropia (2), microgyria and pachygyria (2). Mean follow-up: 18 ± 4.7 (16-27 months). Drop attacks stopped in all the patients. Seizure frequency and duration decreased >90% (11) and >50% (5). HH: Type II (2), Type III (2), Type IV (3). 5 had IA outcome. CONCLUSION: The article emphasizes the role of endoscopic procedures for epilepsy surgery and provides a review of literature. This experience may subserve to coin the term "endoscopic epilepsy surgery" for a fast emerging subspeciality in the field of epilepsy surgery.
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OBJECTIVES. To analyze the indications of surgical treatment, surgical management strategies and post-surgical outcome in patients with brainstem glioma (BSG). METHODS. In this retrospective study conducted from 1998 to 2012, 58 patients of surgically treated intrinsic BSG, meeting the inclusion criterion were enrolled. There were 40 males and 18 females, with age range varying from 3 to 55 years. The most common presentation was gait disturbances, either due to cerebellar involvement or motor weakness, followed by motor weakness, ocular involvement and headache. The posteriorly located tumors were operated by midline suboccipital approach (42 patients) and supracerebellar-infratentorial approach (4 patients). Posterolaterally located tumors were operated by retromastoid (10 patients) and all the ventrolateral tumors by subtemporal approach (4 patients). RESULTS. Above 90% patients improved in their neurological status, while 5% deteriorated. Pilocytic astrocytoma was the most common histopathology (41.4%), followed by Grade II astrocytoma (34.5%) and Grade III astrocytoma (24.1%). Overall, 19% patients had postoperative complications and three patients (5%) died in the perioperative period. CONCLUSIONS. Surgery is advocated for patients with well delineated, posteriorly, posterolaterally and ventrolaterally located tumors having slow progression and relative preservation of motor power. BSG can have excellent surgical results with surgeon's experience and modern surgical facilities.
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Neoplasias del Tronco Encefálico/cirugía , Glioma/cirugía , Procedimientos Neuroquirúrgicos/métodos , Adolescente , Adulto , Astrocitoma/mortalidad , Astrocitoma/patología , Astrocitoma/cirugía , Neoplasias del Tronco Encefálico/diagnóstico , Neoplasias del Tronco Encefálico/mortalidad , Niño , Preescolar , Oftalmopatías/etiología , Femenino , Trastornos Neurológicos de la Marcha/etiología , Glioma/diagnóstico , Glioma/mortalidad , Cefalea/etiología , Humanos , Procesamiento de Imagen Asistido por Computador , Imagen por Resonancia Magnética , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/epidemiología , Estudios Retrospectivos , Resultado del Tratamiento , Adulto JovenRESUMEN
Rathke's Cleft Cysts (RCCs) and Craniopharyngiomas (CPs) may represent disease entities on the same etio-pathological spectrum. We report the case of a 36-year-old female presenting with vision loss and menstrual irregularities, imaging shows a predominantly cystic lesion in the sellar region with suprasellar extension. She underwent a microscopic transnasal resection of the lesion. She later presented with recurrent symptoms and increased residual lesion size on imaging, a transcranial excision of the lesion was performed. Histopathology from the initial operative specimen revealed RCC with squamous metaplasia which was BRAF negative, while the specimen from the second surgery revealed BRAF positive papillary stratified squamous architecture suggestive of Papillary CP. This case adds to the evidence that both RCCs and papillary CPs may be the spectrum of the same disease. Further, papillary CPs may be an evolution from the RCCs.
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Quistes del Sistema Nervioso Central , Craneofaringioma , Neoplasias Hipofisarias , Humanos , Craneofaringioma/cirugía , Craneofaringioma/patología , Craneofaringioma/diagnóstico por imagen , Craneofaringioma/diagnóstico , Quistes del Sistema Nervioso Central/cirugía , Quistes del Sistema Nervioso Central/patología , Quistes del Sistema Nervioso Central/diagnóstico por imagen , Femenino , Adulto , Neoplasias Hipofisarias/patología , Neoplasias Hipofisarias/cirugía , Neoplasias Hipofisarias/diagnóstico por imagenRESUMEN
Pituitary carcinoma is a rare entity comprising 0.1-0.2% of all pituitary tumors and presents significant diagnostic and therapeutic challenges. Intraspinal drop metastasis in these tumors is even rarer. We report a case of a prolactin secreting pituitary carcinoma with intracranial metastasis and multiple intraspinal drop metastasis. This is the first case where 68Gallium labelled [1,4,7,10 - tetraazacyclododecane - 1,4,7,10 - tetraacetic acid] -1- NaI3 - octreotide (68Ga-DOTANOC) whole-body positron emission tomography-computed tomography (PET-CT) has been used in a case of malignant prolactinoma, in an attempt to ascertain the somatostatin receptor (SSTR) expression on tumor cells. Through this paper, we suggest that SSTR targeted radionuclide therapy could have a potential role in aggressive pituitary tumors and pituitary carcinomas similar to the promising role of lutetium-labelled peptides in inoperable or metastasized gastroentero-pancreatic neuroendocrine tumors (GEP-NETs).
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Neoplasias Hipofisarias , Humanos , Neoplasias Hipofisarias/radioterapia , Neoplasias Hipofisarias/diagnóstico por imagen , Neoplasias Hipofisarias/metabolismo , Prolactinoma/diagnóstico por imagen , Prolactinoma/radioterapia , Tomografía Computarizada por Tomografía de Emisión de Positrones , Masculino , Adulto , Compuestos Organometálicos/uso terapéutico , Prolactina/metabolismo , Femenino , Neoplasias Encefálicas/radioterapia , Neoplasias Encefálicas/diagnóstico por imagen , Neoplasias Encefálicas/secundario , Persona de Mediana Edad , Receptores de Somatostatina/metabolismo , Octreótido/análogos & derivados , Octreótido/uso terapéuticoRESUMEN
BACKGROUND: In neurosurgical practice, continuous care after discharge and the ability to detect subtle indicators of clinical deterioration are mandatory to prevent the progression of a disease. The care of 'unknown' patients discharged to rehabilitation homes may not have this privilege, especially in resource-poor countries such as India. OBJECTIVE: We have attempted to study the causes and outcomes of re-admissions of 'unknown' patients with previous traumatic brain injury (TBI) to estimate the quality of nursing care in our rehabilitation centers. MATERIAL AND METHODS: The electronic hospital records of all consecutive 'unknown' TBI patients with unplanned re-admissions at our institute from January 2014 to December 2018 were retrospectively reviewed and analyzed for the factors determining the risk and outcomes of re-admission. RESULTS: Out of 245 patients sent to rehabilitation homes at discharge, 47 patients (19.18%) were re-admitted. A total of 33 patients (70%) were re-admitted between 1 month and 1 year. Out of these, 38 patients (80.9%) were re-admitted because of preventable causes. Fifteen patients (31.9%) died during the hospital stay. The rest of the 32 (68%) patients were discharged after the management of the concerned condition with an average hospital stay of 9 ± 11.1 days. The average Glasgow coma scale (GCS) at re-admission of the patients who died was 6 (range 3-11). Two patients were brought in the brain dead status, whereas 20 patients (42.6%) had a GCS of 5 or below at the time of re-admission. The risk of mortality among patients with non-preventable causes was 88.9% (8/9) compared to preventable causes 18.4% (7/38). However, preventable causes for re-admission are much more common, resulting in nearly a similar overall contribution to mortality. CONCLUSIONS: There is a high rate of mortality and morbidity in 'unknown' patients with TBI because of poor post-discharge care in developing countries. Because preventable causes are the major contributor to re-admissions, the re-admission rate is a good indicator of a lack of adequate rehabilitative services. The need for improving the post-discharge management of 'unknown' patients with TBI in resource-poor countries cannot be over-emphasized.
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Lesiones Traumáticas del Encéfalo , Países en Desarrollo , Readmisión del Paciente , Humanos , Lesiones Traumáticas del Encéfalo/rehabilitación , Lesiones Traumáticas del Encéfalo/mortalidad , Masculino , Femenino , India , Adulto , Readmisión del Paciente/estadística & datos numéricos , Estudios Retrospectivos , Persona de Mediana Edad , Escala de Coma de Glasgow , Centros de Rehabilitación , Adulto Joven , Tiempo de Internación/estadística & datos numéricos , Alta del Paciente/estadística & datos numéricos , AdolescenteRESUMEN
BACKGROUND: Hemispherotomy (HS) is an effective treatment for unilateral hemispheric onset epilepsy. There are few publications for HS in adults, and there is no series comparing adults and pediatric patients of HS. OBJECTIVE: To compare the hemispherotomies done in adult patients with pediatric ones in terms of efficacy and safety. METHODS: Data was prospectively collected for HS patients (up to 18 years and more) from Aug 2014 to Aug 2018. Comparison between the groups was made for seizure onset, duration of epilepsy, frequency of seizures, number of drugs, intraoperative blood loss, postoperative seizure control, postoperative stay, postoperative motor functions, and preoperative and postoperative intelligence quotient. Follow-up was one year. RESULTS: A total of 61 pediatric and 11 adults underwent HS. The seizure onset was earlier in children, and the duration of epilepsy was longer in adults. The frequency of seizures per day was more in children being 14.62 ± 26.34 in children, and 7.71 ± 5.21 per day in adults (P - 0.49). The mean number of drugs was similar in the preoperative and postoperative periods in both. Class I seizure outcome was similar in both the groups being 85.24% in children and 90.9% in adults (P - 0.56). Blood loss, postoperative stay, was similar in both the groups. No patient had a new permanent motor deficit. Power worsened transiently in 1 pediatric patient and in 4 adult patients. The visual word reading and object naming improved in both the groups (no intergroup difference), and IQ remained the same in both groups. One adult patient had meningitis, and another had hydrocephalus requiring shunt placement. CONCLUSION: Hemispherotomy is a safe and effective procedure in adults as in children in appropriately selected patients.
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Epilepsia , Hidrocefalia , Adulto , Humanos , Niño , Convulsiones/cirugía , Pérdida de Sangre Quirúrgica , Epilepsia/cirugía , Hemorragia PosoperatoriaRESUMEN
Background: Surgical site infection (SSI) rates (1-9%) remain high despite the widespread adoption of infection control bundles. Topical vancomycin has emerged as an effective strategy to reduce the rate of SSI in patients undergoing spinal surgery including instrumentation. However, its use and efficiency in cranial neurosurgery is not well established. The aim of this study is to study the efficacy of topical vancomycin in cranial neurosurgery. Methods: A systematic search was performed according to Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines. Data regarding type of surgery, use of implants, the dose of vancomycin, technique of administration in each study, outcomes, rate of SSI, and the interval between surgery and SSI; possible complications related to antibiotic use were collected. Results: A total of 12 studies were included in the qualitative analysis with 3,446 patients. SSI developed in 1.6% of the patients in the vancomycin group as compared to 5.28% in the control group. The pooled risk ratio was 0.24 with 95% CI: 0.12-0.51 (P-value: <0.00001). The difference between the subgroups was significant (P-value: < 0.00001). The number needed to treat (NNT) was 27.2. The studies showed low heterogeneity with an I2 of 24%. Meta-regression analysis showed that the number of patients in a study, duration of follow-up, and year of publication did not contribute significantly to effect size. Conclusion: The limited systemic absorption of vancomycin and broad-spectrum led to its widespread applicability in the prevention of SSI in all types of cranial neurosurgery. Cases with implantable pulse generators, cranioplasty, and cerebrospinal fluid (CSF) diversion procedures have all demonstrated their unequivocal effectiveness.
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Infección de la Herida Quirúrgica , Vancomicina , Humanos , Vancomicina/uso terapéutico , Infección de la Herida Quirúrgica/prevención & control , Infección de la Herida Quirúrgica/tratamiento farmacológico , Infección de la Herida Quirúrgica/etiología , Antibacterianos/uso terapéutico , Procedimientos Neuroquirúrgicos/efectos adversosRESUMEN
The Theory of Mind deficit due to cognitive-affective disintegration is a poorly understood cognitive consequence of cortical and subcortical disruption in right temporal lobe epilepsy. Following Marr's trilevel approach, we used the material-specific processing model to understand the Theory of Mind deficit in drug-resistant epilepsy (N = 30). We examined pre- and post-surgery changes in first-order (somatic-affective, non-verbal component) and second-order Theory of Mind (cognitive-verbal component) in three groups formed using: (i) seizure side (right versus left), (ii) right temporal epilepsy (right temporal lobe epilepsy versus non-right temporal lobe epilepsy), and (iii) right temporal lobe epilepsy with amygdalohippocampectomy (right temporal lobe epilepsy versus left temporal lobe epilepsy amygdalohippocampectomy versus non-amygdalohippocampectomy). We observed a marked deficit in the first-order Theory of Mind in the right temporal lobe amygdalohippocampectomy group; we mapped this deficit to decline in the non-verbal component of Theory of Mind (somatic-affective component). Preliminary results support using a material-specific processing model to understand the Theory of Mind deficits in right temporal lobe epilepsy amygdalohippocampectomy. Malleability of verbal processing in presence of deterioration of non-verbal processing might have clinical relevance for post-surgery recovery in right temporal lobe epilepsy amygdalohippocampectomy. Documenting the material-specific nature of deficits (verbal versus non-verbal) in non-western, linguistically, and socioeconomically diverse country enables us to understand the problem of heterogeneity in post-surgery cognitive consequences in the right amygdalohippocampectomy.
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Background: Corpus callosotomy (CC) is a major disconnection procedure that functionally isolates the cerebral hemispheres, thereby interrupting the spread of epileptic activity from one hemisphere to the other. It is extremely useful in children suffering from non-localized drug refractory epilepsy, especially drop attacks. The technique has evolved from microscopic to minimally invasive endoscopic surgery. The extent of callosotomy also varies based on the institutional practices ranging from anterior 1/3rd to total corpus callosotomies (TCC). The performance of TCC in conjunction with anterior, posterior, and hippocampal commissurotomies was described for the first time by the senior author from our institution. Objective: To describe the technique of performing endoscopic total corpus callosotomy, and pan commissurotomy using the interhemispheric corridor. Methods: A seven-year-old right-handed male child with seizure onset at the age of six months presented with three types of semiologies consisting of myoclonic jerks, frequent head drops and tonic posturing involving right upper and lower limbs with secondary generalization. Results: Video electroencephalography (VEEG) revealed diffuse slowing of the background, and slow spike and wave pattern. Generalized paroxysmal fast activity (GPFA) was noted in the VEEG, suggestive of LGS. MRI brain revealed bilateral parieto-occipital gliosis and gross brain atrophy. Ictal SPECT localized to left temporo-occipital area, while magnetoencephalography revealed bilateral temporal localization. Patient underwent TCC with pancommissurotomy. The patient was seizure-free (ILAE Class 3) at one-year follow up with no drop attacks, and significant reduction noted in other seizure types. Conclusion: Endoscopic corpus callosotomy and pan commissurotomy using the interhemispheric corridor is an elegant and minimally invasive technique best suited for appropriately selected children with refractory epilepsy.
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Epilepsia Refractaria , Síndrome de Lennox-Gastaut , Niño , Cuerpo Calloso/diagnóstico por imagen , Cuerpo Calloso/cirugía , Epilepsia Refractaria/diagnóstico por imagen , Epilepsia Refractaria/cirugía , Electroencefalografía , Humanos , Lactante , Síndrome de Lennox-Gastaut/complicaciones , Síndrome de Lennox-Gastaut/cirugía , Imagen por Resonancia Magnética , Masculino , Convulsiones/complicaciones , Resultado del TratamientoRESUMEN
Background: Intraoperative trans-esophageal migration of pulled-out screws, especially while using the zero-profile implant system, has been rarely reported in the literature. Objective: In this technical note, we are describing a simple technique to retrieve a trans-esophageally migrated pulled-out screw using a suction catheter. Material and Methods: A 32-year-old female presented with spastic quadriparesis. She underwent C5-C6 anterior cervical discectomy and fusion (ACDF). Nine months following the surgery, X-ray cervical spine showed implant loosening and failure of fusion across the instrumented disc space. However, during revision surgery, the loosened screw could not be located visually in the initial attempts, though it could be felt by probing the prevertebral space with the index finger. Intraoperative X-rays showed that the screw migrated curiously in the cranial direction as the surgical field was probed further manually. The screw was then finally retrieved using Magill's forceps assisted by video laryngoscopy assisted by intermittent negative pressure application via a blunt-tipped suction catheter. Results: She was discharged home on a Philadelphia collar, and at 1 year of follow-up, she was completely asymptomatic. Conclusion: Perforation of the aerodigestive tract by a displaced cervical spine implant is an uncommon complication. Manipulation during surgery may cause the implants embedded into the wall of the aerodigestive tract to become dislodged and then migrate into the pharyngeal lumen. In resource-constrained situations or when intraoperative endoscopy is not available, a trial of screw retrieval using a suction catheter may be attempted.
Asunto(s)
Fusión Vertebral , Adulto , Tornillos Óseos/efectos adversos , Catéteres , Vértebras Cervicales/diagnóstico por imagen , Vértebras Cervicales/cirugía , Discectomía , Femenino , Humanos , Fusión Vertebral/métodos , SucciónRESUMEN
Background and Objective: Hemispherotomy surgery in adults is shrouded in doubts regarding the functional outcome. The age at surgery alone should not be the deciding factor for surgery. Language paradigms were used in functional magnetic resonance imaging (fMRI) to confirm the role played by the age at the onset of seizures to predict the postoperative functional outcome. The objective of the study was to formulate an optimal strategy for patient selection for the left-sided hemispherotomy in adults, based on functional outcome analysis. Materials and Methods: A retrospective analysis of 20 participants (age at surgery 1-26 years) who underwent left hemispherotomy (over a 5-year period) was conducted. The language and motor functional assessments of 18 participants (13 pediatric and five adult participants; attrition of participants- two) were recorded at presentation and during follow-up visits. After approval was obtained from the Institutional Ethics Committee, 13 cooperative participants (eight pediatric and five adult participants) underwent language fMRI. Motor fMRI with both active and passive paradigms was done in 16 participants. Results: All 18 participants with a mean follow-up of 24 months had class I seizure-free outcome. Of these 18, five were adults (mean age = 21 years, range: 18-22 years) and 13 were in the pediatric age group (mean age = 8 years, range: 2-15 years). Postoperatively, four adults retained both verbal fluency and language comprehension at a mean follow-up period of 38 months (range: 24-48 months). Their pre- and post-op language fMRI showed word generation and regional activations for semantic comprehension in the right hemisphere. The motor area activations were seen in the right hemisphere in two and in the left hemisphere in two participants. Among the pediatric participants, four (group I [n = 4/13]) who had good language outcome showed activations in the right hemisphere. In two participants (group II [n = 2/13]) who deteriorated postoperatively, the activations were in the left hemisphere. Five participants (group III [n = 5/13]) who retained the telegraphic language postoperatively had bilateral activations of semantic comprehension areas in fMRI. All 13 pediatric participants had motor area activations seen in the left hemisphere, similar to controls. Conclusion: Left hemispherotomy can be advised to adults with comparably good postoperative language and motor outcome as in the pediatric age group, provided the weakness is acquired perinatally or below the age of 7 years. The fMRI is a valuable tool to aid in patient selection.
Asunto(s)
Epilepsia , Trastornos del Lenguaje , Adolescente , Adulto , Niño , Preescolar , Epilepsia/cirugía , Humanos , Lenguaje , Imagen por Resonancia Magnética , Estudios Retrospectivos , Adulto JovenRESUMEN
Background: Patients with perinatal hypoxia (PH) and drug-refractory epilepsy (DRE) often have bilateral parieto-occipital gliosis. Surgical management of such patients is a dilemma. Objective: To identify preoperative determinants for unilateral disconnection vs callosotomy, and analyze the surgical outcome in such patients. Methods and Material: This was a retrospective analysis of patients with DRE and history of PH, with MRI abnormalities restricted to bilateral posterior quadrants. Preoperative semiology, epilepsy duration and seizure frequency were recorded. Based on the concordance between the results of non-invasive tests, patients underwent either posterior quadrant disconnection (PQD) or corpus callosotomy (CC). Preoperative variables were analyzed and corelated to the postoperative seizure freedom. Results: Fourteen patients were identified, 6 underwent PQD and 8 underwent CC. At follow up of 39.17 ± 23.75 months, 66.66% of patients (4/6) in the PQD subgroup had an ILAE Class I outcome. While none in the CC group attained seizure freedom, 87.5% (7/8) had more than 50% reduction in seizure frequency (follow up: 42 ± 27.31 months). Patients with a poor outcome had significantly greater seizure frequency (P = 0.05) and history of drop attacks (P = 0.04) in both the groups. Magnetoencephalography (MEG) accurately localized the epileptogenic zone in all of the patients with good outcome (P = 0.015). Concordance with single photon emission tomography (SPECT) was also a predictor of favorable outcome (P = 0.041). Conclusions: A history of drop attacks with high seizure frequency is associated with poor postoperative seizure outcome. Unilateral PQD is feasible and leads to superior seizure-free outcomes, even in cases with widespread and bilateral imaging and electrical abnormalities, provided the other preoperative investigations are concordant in localizing the epileptogenic zone.