Comparative evaluation of H&H and WFNS grading scales with modified H&H (sans systemic disease): A study on 1000 patients with subarachnoid hemorrhage.

The comparative studies on grading in subarachnoid hemorrhage (SAH) had several limitations such as the unclear grading of Glasgow Coma Scale 15 with neurological deficits in World Federation of Neurosurgical Societies (WFNS), and the inclusion of systemic disease in Hunt and Hess (H&H) scales. Their differential incremental impacts and optimum cut-off values for unfavourable outcome are unsettled. This is a prospective comparison of prognostic impacts of grading schemes to address these issues. SAH patients were assessed using WFNS, H&H (including systemic disease), modified H&H (sans systemic disease) and followed up with Glasgow Outcome Score (GOS) at 3 months. Their performance characteristics were analysed as incremental ordinal variables and different grading scale dichotomies using rank-order correlation, sensitivity, specificity, positive predictive value, negative predictive value, Youden's J and multivariate analyses. A total of 1016 patients were studied. As univariate incremental variable, H&H sans systemic disease had the best negative rank-order correlation coefficient (-0.453) with respect to lower GOS (p < 0.001). As univariate dichotomized category, WFNS grades 3-5 had the best performance index of 0.39 to suggest unfavourable GOS with a specificity of 89% and sensitivity of 51%. In multivariate incremental analysis, H&H sans systemic disease had the greatest adjusted incremental impact of 0.72 (95% confidence interval (CI) 0.54-0.91) against a lower GOS as compared to 0.6 (95% CI 0.45-0.74) and 0.55 (95% CI 0.42-0.68) for H&H and WFNS grades, respectively. In multivariate categorical analysis, H&H grades 4-5 sans systemic disease had the greatest impact on unfavourable GOS with an adjusted odds ratio of 6.06 (95% CI 3.94-9.32). To conclude, H&H grading sans systemic disease had the greatest impact on unfavourable GOS. Though systemic disease is an important prognostic factor, it should be considered distinctly from grading. Appropriate cut-off values suggesting unfavourable outcome for H&H and WFNS were 4-5 and 3-5, respectively, indicating the importance of neurological deficits in addition to level of consciousness.

Choice of fluid therapy in patients of craniopharyngioma in the perioperative period: A hospital-based preliminary study.

BACKGROUND: Electrolyte imbalance and acute diabetes insipidus (DI) are the most common complications in patients undergoing craniopharyngioma surgery. Improper management of water and electrolyte imbalance is common cause of morbidity and mortality. Data is sparse and controversial regarding the choice of fluid therapy in this population during perioperative period. METHODS: In this retrospective-prospective study involving 73 patients (58 retrospective), the type of fluid therapy was correlated with occurrence of hypernatremia, hyponatremia, DI, morbidity, and mortality. In the retrospective study, 48 patients received normal saline and 10 received mixed fluids as per the prevailing practice. In the prospective group, five patients each received normal saline, half normal saline, and 5% dextrose randomly. RESULTS: The sodium values were significantly higher in first 48 h in the group that received normal saline compared with other groups (P < 0.001). The use of normal saline was associated with higher incidence of hypernatremia, DI, and mortality (P = 0.05), while the group that received 5% dextrose was associated with hyponatremia, hypoglycemia, and seizures. There was no perioperative hypotension with use of any of the fluids. CONCLUSION: Our results indicate half normal saline was fluid of choice with diminished incidence of water and electrolyte abnormalities without increase in mortality during postoperative period.

Ruptured venous aneurysm of cervicomedullary junction.

BACKGROUND: Ruptured venous aneurysm is often seen with arterio-venous malformation (AVM) or developmental venous anomaly (DVA). However, isolated venous aneurysm is unusual. CASE DESCRIPTION: We present a case of ruptured venous aneurysm that presented with subarachnoid hemorrhage (SAH) and intraventricular hemorrhage (IVH). Digital substraction angiography (DSA) revealed a saccular contrast filling pouch in the left lateral aspect of cervicomedullary junction (CMJ). Endovascular intervention was not a viable option. During surgery, a saccular pliable structure approx. 1.5 × 1 cm was found in the subarachnoid space that was clipped and excised. There were no arterial feeders, no evidence of surrounding AVM, and no dilated perimedullary vein. CONCLUSION: This is perhaps the first reported case of ruptured venous aneurysm (without associated AVM) of CMJ, which was successfully managed surgically. The possible etiologies remain an unnoticed head trauma or a congenital vessel wall abnormality. Surgically clipping and excision remains the treatment of choice for such lesion.

Pediatric aneurysms and vein of Galen malformations.

Pediatric aneurysms are different from adult aneurysms - they are more rare, are giant and in the posterior circulation more frequently than in adults and may be associated with congenital disorders. Infectious and traumatic aneursyms are also seen more frequently. Vein of Galen malformations are even rarer entities. They may be of choroidal or mural type. Based on the degree of AV shunting they may present with failure to thrive, with hydrocephalus or in severe cases with heart failure. The only possible treatment is by endovascular techniques - both transarterial and transvenous routes are employed. Rarely transtorcular approach is needed. These cases should be managed by an experienced neurointerventionist.

Mirror-like aneurysms of proximal anterior cerebral artery: report of a case and review of literature.

'Mirror-like' or 'twin' aneurysms, which are located bilaterally on corresponding arteries, constitute less than 5% of overall aneurysms and mirror aneurysms on proximal anterior cerebral artery (A1) have never been reported in the past. We report a case of bilateral proximal A1 segment aneurysms (mirror). The approach to this patient is being described and the literature reviewed. The proximal A1 segment aneurysm is more approachable from the contralateral side. In case of mirror A1 aneurysms, the approach may be better from contralateral side of the larger aneurysm.

Giant cell tumour of the clivus.

Primary giant cell tumours of the craniospinal axes are rare lesions. These are benign, localized and lytic bony lesions with occasional malignant behaviour. Their clinical behaviour is unpredictable and, hence, management remains controversial. Radical excision of bony lesion, with adjuvant therapy helps in achieving the desired outcome. In the present communication, we present malignant giant cell tumour of clivus, managed successfully with surgical decompression and adjuvant therapy. Patient remains symptom-free at 2 years of follow-up.

Change in tissue thromboplastin content of brain following trauma.

BACKGROUND: Tissue thromboplastin (TTP) is an integral membrane protein contributing to coagulopathy after trauma of brain, which is a rich source of TTP. AIMS: A study was undertaken to establish the TTP content of various areas of normal brain and estimate the changes in TTP activity of brain in response to varying degrees of trauma. MATERIALS AND METHODS: Samples from different areas of brain of ten cadavers were used as controls and they were compared with contused brain tissue obtained after surgery in 25 head injury (HI) patients of varying severity. RESULTS: In the study group, the TTP activity of the frontal, parietal, and temporal lobes after HI was significantly raised in contrast to that of the control group. The TTP activity was also significantly higher in the severe HI patients than those having moderate HI. The mode of injury and the time lapse after HI had no significant bearing on the TTP activity. Subjects above 40 years of age demonstrated a higher mean TTP activity after HI, though it was not statistically significant. CONCLUSION: The study provides quantitative data on TTP activity of normal brain and highlights the role of TTP in coagulopathy following HI through its increased activity after HI, more so in the severe HI group.

Radiation-induced brain disorders in patients with pituitary tumours.

Radiation-induced brain disorders (RIBD) are uncommon and they are grave sequelae of conventional radiotherapy. In the present report, we describe the clinical spectrum of RIBD in 11 patients who received post-surgery conventional megavoltage irradiation for residual pituitary tumours. Of these 11 patients (nine men, two women), seven had been treated for non-functioning pituitary tumours and four for somatotropinomas. At the time of irradiation the age of these patients ranged from 30 to 59 years (mean, 39.4 +/- 8.3; median, 36) with a follow-up period of 6-96 months (mean, 18.3 +/- 26.4; median, 11). The dose of radiation ranged from 45 to 90 Gy (mean, 51.3 +/- 13.4; median, 45), which was given in 15-30 fractions (mean, 18.6 +/- 5.0; median, 15) with 2.8 +/- 0.3 Gy (median, 3) per fraction. The biological effective dose calculated for late complications in these patients ranged from 78.7 to 180 Gy (mean, 99.1 +/- 27.5; median, 90). The lag time between tumour irradiation and the onset of symptoms ranged from 6 to 168 months (mean, 46.3 +/- 57.0; median, 57). The clinical spectrum of RIBD included new-onset visual abnormalities in five, cerebral radionecrosis in the form of altered sensorium in four, generalized seizures in four, cognitive dysfunction in five, dementia in three and motor deficits in two patients. Magnetic resonance imaging (MRI)/CT of the brain was suggestive of radionecrosis in eight, cerebral oedema in three, cerebral atrophy in two and second neoplasia in one patient. Associated hormone deficiencies at presentation were hypogonadism in eight, hypoadrenalism in six, hypothyroidism in four and diabetes insipidus in one patient. Autopsy in two patients showed primitive neuroectodermal tumour (PNET) and brainstem radionecrosis in one, and a cystic lesion in the left frontal lobe following radionecrosis in the other. We conclude that RIBD have distinctive but varying clinical and radiological presentations. Diabetes insipidus and PNET as a second neoplastic disorder in adults following pituitary irradiation have not been reported previously.

Intraventricular sodium nitroprusside therapy: a future promise for refractory subarachnoid hemorrhage-induced vasospasm.

A prospective study was carried out to evaluate the efficacy of intraventricular sodium nitroprousside (SNP) in the reversal of refractory vasospasm secondary to aneurysmal subarachnoid hemorrhage (SAH). Ten patients of aneurysmal SAH with symptomatic vasospasm, corroborated on Transcranial Doppler (TCD) and/or angiography, were included in the study. The mean age distribution of the patients was 50.8 years (range 33-65 years) with an equal number of males and females. Once vasospasm was refractory even after 12 hours of SAH therapy, intraventricular SNP was instilled in an escalating dose and the reversal of vasospasm was monitored on TCD and/or angiography. All patients showed improvement in TCD velocity on day 0 through day 3. Partial to complete reversal of vasospasm was demonstrated on angiography in all the patients, though not in all the vessels. Two patients who had weakness of limbs due to vasospasm improved following intraventricular SNP therapy. Vomiting was the commonest adverse effect (7/10). Three patients had mild fluctuation in blood pressure. The overall outcome was good in 6 out of 10 patients. The study suggests that intraventricular SNP therapy is effective in reversing the changes even in established cases of SAH-induced vasospasm.

Intermittent low dose intrathecal sodium nitroprusside therapy for treatment of symptomatic aneurysmal SAH-induced vasospasm.

Eight patients with aneurysmal subarachnoid haemorrhage (SAH) received intrathecal sodium nitroprusside therapy (ITSNPT) in the form of intermittent bolus doses for delayed cerebral vasospasm after undergoing clipping of an aneurysm. Five patients were administered ITSNPT to combat refractory symptomatic vasospasm while three patients received prophylactic ITSNPT in view of the possibility of imminent clinical vasospasm. In five patients the therapy was instituted through the intraventricular route, while in three the drug was instilled into the basal cistern. Sodium nitroprusside (SNP) was administered at an interval of 3-12 h, in varying bolus doses ranging between 2 and 5 mg depending upon the (i) mean flow velocity values on transcranial Doppler study and (ii) clinical response. The end point of ITSNPT was either relief of vasospasm, any adverse effect or contraindication to continuation of ITSNPT. All except one patient survived. One patient had mild residual neurological deficit following an infarct. All the three patients who received prophylactic ITSNPT had good outcomes.

Recurrent intramedullary cervical ependymal cyst.

We report a rare case of high cervical intramedullary ependymal cyst in a young boy. This was associated with atlantoaxial dislocation. After partial removal and marsupialization, the cyst recurred and needed radical total resection.

Primary central nervous system lymphoma: experience of 46 cases with review of literature.

Primary central nervous system lymphomas (PCNSL) constitutes only 1.0 to 1.5% of all brain tumors. Their incidence has gone up over tenfold in the last 25 years. Though, there has been an association of PCNSL with acquired immune deficiency syndrome (AIDS), yet the increased incidence of PCNSL appears to be real and unrelated to AIDS and organ transplantation. This increased incidence could be because of improvement in diagnostic technology and practice. The outcome remains gloomy despite surgical resection, radiotherapy and intensive adjuvant chemotherapy regimens, as majority of the patients succumb to the disease, with only 30-40% survival in patients under 70 years of age.

Intramedullary cysticercosis : MRI diagnosis.

Three cases of dorsal intramedullary cysticercosis presenting as spastic paraparesis or paraplegia are reported. A definite preoperative diagnosis, using MRI, was made in two cases while in the third it was strongly suspected. One paraplegic patient regained full function whereas in the other two the deficit persisted even after successful cyst excision. The pathogenesis and recovery are discussed in the light of the MRI findings.

Calcified falx meningioma.

A totally calcified mid third falcine meningioma in an elderly male patient is presented. An uneventful enmasse excision was performed. Advantages of positioning on ipsilateral side for paramedian extracerebral lesions are highlighted.

Anterior surgical approaches to the sub-axial cervical spine.

Anterior cervical spine surgery has come of age, as a golden route for treating anteriorly placed cervical compressions ranging from simple prolapsed disc to long segment pathologies like ossification of posterior longitudinal ligaments and cervical spondylotic myelopathy. Numerous technical modifications of the procedure are described. The role of stabilisation established for several pathologies, is still debateable in surgery for cervical disc. Bone is the ideal tissue for fusion. Hydroxyapetite implants are goods, but costly for our set up. Methylmethacrylate has a limited role in elderly patients with malignancy and a short life expectancy. Anterior cervical instrumentation has mushroomed over the last decade. Acceptable as methods of immediate stabilisation, the choice of the system varies with the surgeon. The authors use simple titanium plates with locking screws for the purpose.

Pituitary adenoma and parasagittal meningioma: an unusual association.

Simultaneous detection of an intracranial meningioma with a pituitary tumour prior to radiotherapy is an extremely uncommon occurrence. Authors have managed an elderly acromegalic lady with an acidophilic pituitary adenoma, who also harboured an asymptomatic anterior third parasagittal meningioma. There were no features of neurofibromatosis. Both tumours were concurrently excised.

Tethered cord syndrome in adults.

BACKGROUND: The tethered cord syndrome (TCS) is usually diagnosed in childhood and its symptomatic onset in adult life is not common. In the present study, we analyzed the data of patients who presented with TCS in adulthood with the aim of studying the clinical spectrum and management strategies. CLINICAL MATERIAL: Over a 5-year period, 18 adult patients (more than 18 years of age) with TCS were investigated with MRI and were operated on. Patients with adult TCS could be divided into two groups. Group 1 included patients who were asymptomatic in childhood and presented for the first time in adult life (10 patients). The second group was comprised of patients with preexisting static skeletal/neurological deformities who presented in adult life with new or progressive symptoms (eight patients). Eleven patients had cutaneous stigmata, 15 had motor or sensory deficit, nine had back/leg pain, eight had leg atrophy, and six had sphincter disturbances. The most frequent MRI finding was a low lying cord with an intradural and/or extradural lipoma. The cord was detethered surgically and the tethering lesion excised. Pain was usually relieved after surgery (8 out of 9), but only a few patients (2 out of 6) had improvement of sphincter dysfunction. CONCLUSIONS: The late presentation of TCS is possibly related to the degree of tethering and the cumulative effect of repeated microtrauma during flexion and extension. Adult patients with persistent back/leg pain and/or neurological or skeletal deformities should be investigated with MRI to establish an early diagnosis. Surgery should be performed in all adult patients with TCS, once the diagnosis is established.

Spinal cord injury without radiographic abnormality in adults.

Spinal cord injury without fractures or bony malalignment on either plain radiographs or computed tomography (SCIWORA) is most commonly found in the paediatric age group. In recent years, magnetic resonance imaging (MRI) has been used to evaluate these patients. The present communication describes SCIWORA in 15 adult patients investigated by MRI. Of the 151 patients with spinal cord injury in 1 year, 15 adult patients had cervical SCIWORA. All patients were evaluated by MRI. The age ranged from 20 - 60 years. Eleven patients had partial cord injury, two had a complete cord syndrome while two had a central cord syndrome. MRI demonstrated an intervertebral disc prolapse in six patients, intramedullary haematoma/contusion in four and cord oedema in four patients. One patient had multiple disc prolapses and associated intramedullary haematoma. Patients with disc prolapse were operated upon and all showed neurological improvement. The rest of the patients were managed conservatively. There was mild improvement in patients with intramedullary haematomas while those with cord oedema alone showed moderate recovery. The pathogenesis of adult SCIWORA is possibly different from that in paediatric age group. Most of the patients with SCIWORA show some abnormality on MR imaging. MRI should therefore be done in all patients with spinal cord injury for diagnostic and prognostic purposes.

Midline and far lateral approaches to foramen magnum lesions.

Twenty patients with foramen magnum lesions were operated upon in the last 5 years at Postgraduate Institute of Medical Education and Research, Chandigarh. The common presenting features were quadriparesis, quadriplegia, diminished sensations, neck pain and respiratory insufficiency. The lesions encountered were meningiomas, neurofibromas, posterior inferior cerebellar artery aneurysms, neurenteric cyst and chordoma. Patients with posterior or posterolaterally placed lesions were operated by the midline posterior approach while those with anterior or anterolateral lesions were managed by the far lateral approach. All mass lesions were excised completely and the aneurysms were clipped. Seventeen patients made good neurological recovery while three died. The latter three patients presented very late. The merits of various surgical approaches to the foramen magnum are discussed.

Spontaneous intracranial hematomas: role of dynamic CT and angiography.

Forty-five patients with spontaneous intracerebral hemorrhage (ICH) were studied prospectively by dynamic CT and cerebral angiography. The accuracy of dynamic CT in demonstrating the underlying vascular cause in ICH was evaluated. Dynamic CT correctly predicted 90% of aneurysms, 83% of AVMs and 100% of normal studies as compared to angiography. Cerebral angiography can be obviated in patients where dynamic CT does not show any obvious vascular anomaly.