Perioperative Variation in Optic Nerve Sheath Diameter - A Prospective Observational Study of Traumatic Brain Injury Patients Undergoing Decompressive Craniectomy.

Background: Measuring optic nerve sheath diameter (ONSD) by transbulbar ultrasonography (TBUS) can suffice non-invasive ICP measurement with considerable accuracy. Objective: The primary objective of this study was to evaluate the perioperative variation in ONSD by TBUS in Traumatic Brain Injury (TBI) patients undergoing emergency craniectomy. Methods: We prospectively compared bilateral ONSD measurements in 45 consecutive TBI cases undergoing decompressive craniectomy under general anesthesia; before and after surgery. A total of 180 ONSD images were obtained and measurements were done by the same investigator blinded to the pre/postoperative nature of the image. Results: Based on preoperative Glasgow Coma Scores, 34 cases (75.5%) had severe TBI; 10 cases (22.2%) moderate TBI; and 1 case (2.2%) mild TBI. Preoperative ONSD in the study population were as 6.625 ± 0.414mm. Average ONSD reduced significantly by 0.249 ± 0.148 mm (P < 0.001) after craniectomy. On pooled analysis of cases undergoing right versus left sided craniectomy average ONSD reduced significantly by 0.252 ± 0.173 mm (P < 0.001) and 0.259 ± 0.139 mm (P < 0.001), respectively. ONSD of right eye with left eye and vice-versa were strongly correlated both pre/postoperatively with Pearson correlation coefficients (r)=0.879 (P < 0.001) and r = 0.827 (P < 0.001), respectively. Conclusions: In TBI cases undergoing decompressive craniectomy ONSD is bilaterally increased preoperatively. ONSD reduces significantly immediately after craniectomy; however, the diameters did not near the normal range. There hold a strong correlation between right/left ONSD measurements irrespective of the laterality of injury or side of surgery. Variable elastic properties of ONS in an injured brain can possibly explain our findings.

Implementation and adherence to a speciality-specific checklist for neurosurgery and its influence on patient safety.

BACKGROUND AND AIMS: Neurosurgery involves a high level of expertise coupled with enduring and long duration of working hours. There is a paucity of published literature about the experience with a speciality-specific checklist in neurosurgery. We conducted a cross-sectional observational study to identify the adherence to various elements of the Modified World Health Organization Surgical Safety Checklist (WHO SSC) for neurosurgery by the operating room (OR) team. METHODS: We implemented an intra-operative Modified WHO SSC consisting of 40 tools for neurosurgery, in 200 consecutive elective cases. Trained anaesthesiologists assumed the role of checklist co-ordinator. The checklist divided the surgery into 5 phases, each corresponding to a specific time-period. The adherence rates to various tools were evaluated and areas where the checklist prompted a corrective measure were analysed. RESULTS: A total of 131 cases undergoing craniotomy and 69 cases undergoing spine surgery were studied. With the 40-point modified SSC applied in 200 cases, we analysed a total of 8000 observations. The modified checklist prompted the OR team to adhere to speciality-specific safety practices about application of compression stockings (9.5%); airway precautions in unstable cervical spine (2.5%); precautions for treatment of raised intracranial pressure (10.5%); and intraoperative neuro-monitoring (5%). CONCLUSION: The implementation of Modified WHO SSC for Neurosurgery, by a designated checklist co-ordinator, can rectify anaesthetic and surgical facets promptly, without increasing the OR time. The anaesthesiologist as SSC coordinator can effectively implement an intraoperative checklist ensuring excellent participation of operating room team members.

Asymptomatic Brain Abscess Following Decompressive Craniotomy for Stroke - A Report of Two Cases and Review of the Literature.

Stroke is a significant health problem in both developed and developing nations. The treatment strategies of stroke differ among various centers depending on the available expertise. Nevertheless, stroke contributes to a major economic burden for patients and health institutions. The recovery period after stroke is a critical period wherein various complications can develop in survivors. Among these multiple complications, the formation of brain abscess in the infarcted brain tissue is rare and less well described in the literature. Fever or signs of raised intracranial pressure are the usual manifestation of poststroke brain abscess. We present two unique cases of large brain abscess in patients who survived a malignant stroke. Both the patients were recuperating well after decompressive craniectomy for stroke without any signs of intracranial infection or raised intracranial pressure. Both the patients underwent open drainage of brain abscess, followed by delayed cranioplasty. There are only a few cases of brain abscess reported in the literature in patients who underwent decompressive craniectomy for stroke.

The Outcome of Medical Management of Chronic Subdural Hematoma with Tranexamic Acid - A Prospective Observational Study.

INTRODUCTION: The conservative management of Chronic subdural hematoma (CSDH) is controversial. Many drugs have been tried in the conservative management of CSDH. Tranexamic acid (Txa) is one such drug in the armamentarium for conservative management of CSDH. We conducted a prospective observational study about treatment of CSDH with Txa. MATERIAL AND METHODS: The study was conducted over three years. The clinical grading was assessed by the Markwalder grading system. All patients who were relatively and mildly symptomatic and willing for conservative management were recruited for the study. All patients were given Txa in the dosage of 750 mg/day in divided doses. The patients were followed up in the neurosurgery out-patient department. RESULTS: There were 27 patients with 30 CSDH during this period who were treated with Txa. There were 20 cases of primary CSDHs and 7 cases of recurrent CSDHs following surgery that were enrolled in the Txa group. The mean volume of treated CSDH was 135.62 ± 92.90 SD. The mean thickness of CSDH enrolled in the study was 14.31 ± 5.47 SD. The mean number of days the patients treated with Txa was 64.83 ± 24.8 SD. There were no complications in any of the patients. All patients had good resolution of the hematomas, and none of the hematomas progressed during conservative treatment. CONCLUSION: The conservative management of CSDH with Txa is both a safe and effective alternative in the absence of life-threatening symptoms.

Spontaneous Change in Density of Colloid Cyst: An Unusual Phenomenon.

BACKGROUND: Colloid cysts of the third ventricle are benign congenital lesions. They are at times totally asymptomatic or may be detected in the evaluation for headache, neurologic disturbances, or psychiatric disturbances. They may sometimes cause grave consequences such as coma or even sudden death. The radiologic appearance is unique and important for making decisions in the management. CASE DESCRIPTION: We report a patient with a colloid cyst who presented to us after sudden deterioration in consciouness. It was noted that he underwent brain computed tomography (CT) scan 10 months ago in the evaluation of headache. Compared with previous CT scan, there was a sudden change in the density and size of the colloid cyst with obstructive hydrocephalus. This unique change in the character of the colloid cyst occurred without any intervention. We discuss the possible etiologies behind this phenomenon along with a review of the literature. CONCLUSIONS: This case stands out remarkably because it is only the second case in literature with similar natural history.

The Outcome of Aneurysm Clipping in Septuagenarians - A Retrospective Analysis in a Basic Neurovascular Unit.

INTRODUCTION: The management of aneurysmal subarachnoid hemorrhage (SAH) in the elderly is challenging. Clipping as the definitive treatment is less well tolerated by the elderly population. The outcome is anticipated to be more glimmer in poor grade SAH and in a setup which lacks modern neurovascular gadgets. We present our experience of surgical clipping in elderly patients in such a basic neurovascular unit. MATERIALS AND METHODS: A retrospective analysis of hospital records of elderly patients between 70 and 79 of age who underwent surgical clipping of intracranial aneurysms between 2015 and 2017 was done. The patients' characteristics, comorbidities, aneurysm characteristics, intraoperative complications, and postoperative complications were studied to determine the factors influencing an unfavorable outcome. All information was entered into a database (Microsoft Excel) and analyzed using SPSS trial version 16. Outcomes were grouped into a favorable outomce which included Glasgow Outcome Scale scores of 4 and 5, whereas an unfavorable outcome which included Glasgow Outcome Scale scores of 1, 2, and 3. RESULTS: There were 21 patients with aneurysms located either in the anterior or posterior circulation or both. All underwent standard craniotomy and clipping pertaining to that particular type of aneurysm. A favorable outcome was achieved in 48% of the patients and 52% had an unfavorable outcome. The duration of surgery, number of days on ventilator, and presence of hydrocephalus were the factors found to be statistically significantly associated with unfavorable outcomes. CONCLUSION: A team approach consisting of a neuroanaesthetist, neurosurgeons, and critical care personnel can have a huge impact on the postoperative outcome.

Flying with Colloid Cyst: A Cautionary Note.

BACKGROUND: Colloid cysts are benign and rare tumors of the brain. The growth rates of these tumors are unpredictable. These cysts can increase in size and obstruct the cerebrospinal fluid pathways producing obstructive hydrocephalus. Consequently, this can manifest as acute severe headaches followed by deterioration in consciousness, or even sudden death in patients. Such remarkable episodes occurring in patients during air travel have been reported sparsely in the literature. CASE DESCRIPTION: In this report, we narrate the ordeal of a patient who had severe headache followed by loss of consciousness during his air travel. After his arrival, he was taken to a referral center where the diagnosis of a colloid cyst obstructing the cerebrospinal fluid pathway resulting in acute obstructive hydrocephalus was revealed. We analyze the physiologic effects of cabin pressure and high altitude on the intracranial pressure and present a brief review of the literature. CONCLUSIONS: Changes in cabin pressure during flight may play a role in worsening of intracranial pressure in patients with colloid cyst with marginal brain compliance.

A shunt lost in the mists of time.

Ventriculo peritoneal shunts offer promising results in the management of hydrocephalus. However, they are not without complications. Shunt migrations and extrusions have been reported plenty of times in the literature. Migration of both the proximal and distal catheter has been reported. However; entire shunt migrations are rare and can result in worsening of the clinical condition of the patient. We report a case of entire shunt migration in to the abdominal cavity which was diagnosed during her childhood 8 years after shunt surgery. The parents of the child were advised shunt removal and new shunt insertion but they did not agree to it and they lost follow-up. The patient attended neurosurgery outpatient clinic 24 years later for evaluation of traumatic brain injury, when this finding was incidentally detected. She remained asymptomatic for this condition during all these years. To our knowledge, such incidence of entire shunt migration being remaining asymptomatic for such a long duration has never been reported in the literature.

Burden of Dengue-related Neurosurgical Emergencies during an Epidemic: A Tertiary Care Experience.

Dengue is one of the most common flavivirus infections which can manifest from common flu-like fever to fatal hemorrhagic complication. Epidemics of dengue return every year with peaks during the rainfall claiming substantial number of lives in the tropical and subtropical regions of the world. We present manifestations of dengue in patients who underwent neurosurgery in a tertiary referral center during such an epidemic. There were total four patients referred for neurosurgical intervention as sequelae to dengue coagulopathy. Among them, three had intracranial bleeds and one had spinal cord hematoma along with intracranial hemorrhages. This small series includes the youngest reported case of dengue coagulopathy with intracranial bleed and only the second case of spontaneous intraspinal hematoma sequelae to dengue hemorrhagic fever. The situations where patients contract dengue in a setting of neurosurgical intervention are grave. The margin of safety in the presence of dengue coagulopathy is narrow. The surgeon has to outweigh benefit against risk of surgery in each individual.

Hemilaminectomy for Spinal Cord Intradural Tumors: An Institutional Experience.

INTRODUCTION: Laminectomy is the workhorse of spinal cord tumor surgery. This procedure is not without the debilitating sequelae of postoperative pain and delayed kyphosis. Hemilaminectomy is an alternate option to laminectomy which offers the advantage of preserving the posterior supporting structures of the spine on the contralateral side. In this study, we analyze the outcome of hemilaminectomy clinically with improvement in pain scores and Nurick's grade as well as radiologically by assessing for the development of delayed kyphosis. We also discuss the technique and operative nuances of hemilaminectomy in intradural extramedullary tumors of the spinal cord. MATERIALS AND METHODS: All patients with intradural spinal cord tumors were included in the study. All patients underwent unilateral hemilaminectomy (UHL) depending on the laterality of the tumor on the preoperative magnetic resonance imaging. Preoperative neurologic status was assessed with Nurick's grade for tumors involving the cervicothoracic region tumors, and visual analog scale scores were recorded for tumors of Thoracic, Lumbar and Lumbosacral regions. The postoperative outcomes were assessed by improvement in respective scales on follow-up. The occurrence of delayed spinal deformity was assessed by follow-up X-rays. Any complications whether intraoperative or postoperative were recorded. RESULTS: There were a total of 34 cases of intradural extramedullary tumors in this study. Patient population consisted of 11 males and 23 females. Total excision was achieved in 31 patients. In three patients, we were unable to achieve complete removal through UHL. In these patients the procedure was converted to total laminectomy. They were excluded from analysis. The distribution of the tumors was in cervical, cervicothoracic, thoracic, lumbar, and lumbosacral region. All patients presented with pain or varying degrees or neurologic deficits. Sixteen patients underwent UHL from the right side, while 18 from the left. There were no intraoperative complications. The neurological status and pain scores of all patients improved postoperatively at 3 and 6 months of follow-up. There was no radiological evidence of kyphosis of the involved segment. CONCLUSION: With a small learning curve, UHL is a good corridor for the removal of intradural extramedullary spinal cord tumors. This approach offers the advantage of less postoperative pain and no postoperative deformity.

Outcome of Ventriculosubgaleal Shunt in the Management of Infectious and Non-infectious Hydrocephalus in Pre-term Infants.

BACKGROUND: Hydrocephalus in premature infants is an onerous disease. In such situations, choosing the best option for cerebrospinal fluid (CSF) diversion is difficult. Ventriculosubgaleal shunt is an effective method of temporary CSF diversion in such situations. In this retrospective study, we compare the outcome of ventriculosubgaleal shunt in premature infants with hydrocephalus of infectious and noninfectious etiology. MATERIALS AND METHODS: All premature children with hydrocephalus secondary to various etiologies who underwent ventriculosubgaleal shunt were studied. The participants were grouped into two depending upon the etiology of hydrocephalus: Group 1 (infectious) and Group 2 (non-infectious). The primary outcome was a successful conversion to ventriculoperitoneal shunt (VPS) and the secondary outcome was mortality. Data were entered into statistical software SPSS version 16 and appropriate statistical analysis was performed to conclude any statistical significance between groups. RESULTS: The study included 16 infants among whom 9 were in the infectious group and 7 in the non-infectious group. Primary end point of conversion to VPS was achieved in 55.5% of patients in group 1 and 85.7% in group 2. The secondary end point, i.e., mortality was observed in 44.4% of patients in group 1 and 14.2% in group 2. The average duration during which this was achieved was 40 days (range 20-60 days) in group 1 and 25 days (range 20-30 days) in group 2. CONCLUSION: Ventriculosubgaleal shunt is a safe and effective procedure in infants awaiting definitive VPS for hydrocephalus of infectious as well as noninfectious origin. There was no statistical difference in the rate of successful conversion to a permanent VPS from ventriculosubgaleal shunt in hydrocephalus of either etiologies. Complications and time for successful conversion were more in postmeningitic hydrocephalus.

Spontaneous Pneumocephalus Secondary to Leaking Myelomeningocele.

Myelomeningocele is one among the most common forms of spinal dysraphism. We report a newborn male child with leaking myelomeningocele who presented with apneic spells. He underwent a magnetic resonance imaging of the neuraxis, which revealed Chiari malformation and severe hydromyelia along with pneumocephalus. He was planned to undergo urgent repair of the neural tube defect but his parents were not willing for surgery. We report this case as spontaneous pneumocephalus secondary to open neural tube defect, which is very rare and sparsely reported.

Analysis and Clinical Importance of Skull Base Fractures in Adult Patients with Traumatic Brain Injury.

AIMS AND OBJECTIVES: Basal skull fracture (BSF) is rare in head injury (HI) patients and occasionally goes unnoticed which may lead to cerebrospinal fluid (CSF) fistula. With changing trends in HI, there is a need to reassess incidence and pattern of BSF pattern, CSF leak, meningitis, and management protocol, especially in this part of the world where detailed literature is lacking. SUBJECTS AND METHODS: We closely followed adult patients admitted with BSF in our institute between January 2013 and December 2014. Associated clinical features were recorded. In case of CSF leak, detailed CSF study was done and patients were managed accordingly. Patients with persistent CSF leak were managed surgically. RESULTS: During the study period, 194 of 5041 HI patients had evidence of BSF (3.85%). BSF was most commonly associated with moderate-to-severe HI (73.19%). About 81.44% patients were male and 29.9% were <30 years. Most common cause was road traffic accident (84.54%). Isolated anterior cranial fossa (ACF) fracture was most common (50%). About 63.92% patients had raccoon eyes. Forty-three patients had CSF leak with CSF rhinorrhea being more common. Culture of only 5 patients suggested bacterial meningitis. CSF leak lasted for more than 10 days in 8 patients, of which 4 patients required surgical repair. CONCLUSIONS: BSF is rare in victims of HI. It is more common in young adult males. ACF fractures are most common in our setup. Clinical signs of BSF are supportive but not definitive; high resolution computed tomography head is gold standard to detect BSF. CSF leak is rare and most of the cases can be managed conservatively. Leak persisting more than 7-10 days has high risk of developing meningitis and likely to need surgical intervention.

The Conundrum of Ventricular Dilatations Following Decompressive Craniectomy: Is Ventriculoperitoneal Shunt, The Only Panacea?

INTRODUCTION: Ventriculomegaly and hydrocephalus (HCP) are sometimes a bewildering sequela of decompressive craniectomy (DC). The distinguishing criteria between both are less well defined. Majority of the studies quoted in the literature have defined HCP radiologically, rather than considering the clinical status of the patient. Accordingly, these patients have been treated with permanent cerebrospinal fluid (CSF) diversion procedures. We hypothesize that asymptomatic ventriculomegaly following DC should undergo aspiration with cranioplasty and be followed up regularly. MATERIALS AND METHODS: All patients with post-DC who were scheduled for cranioplasty and satisfied the radiological criteria for HCP were included. These patients were categorized into two groups. Group 1 included ventriculomegaly with clinical signs attributable to HCP and Group 2 constituted ventriculomegaly but no clinical signs attributable to HCP. All patients in Group 1 underwent ventriculoperitoneal shunt followed by cranioplasty, whereas all patients in Group 2 underwent cranioplasty along with simultaneous ventriculostomy and temporary aspiration of the lateral ventricle. All patients were regularly followed as the outpatient basis. RESULTS: There were 21 patients who developed ventriculomegaly following DC. There were 10 patients in Group 1 and 11 patients in Group 2. The average duration of follow-up was from 6 months to 2 years. Two patients in the shunt group - (group 1) had over drainage and required revision. One patient in aspiration group - (group 2) required permanent CSF diversion. CONCLUSIONS: Cranioplasty with aspiration is a viable option in selected group of patients in whom there is ventriculomegaly but no signs or symptoms attributable to HCP.

PEMLIF-a tale of two stories.

Intervertebral disc prolapse is a common cause of both acute and chronic low back pain. This can result in differential grades of motor and sensory disturbances in lower limbs and even cauda equina syndrome (CES). The neurological manifestations are a result of compression of the spinal cord and roots ventrally in the spinal canal due to the prolapsed disc. However, neurologic deficits owing to compression of the spinal cord dorsally as a result of migration of sequestrated disc fragments are very rare. We present two different cases of back pain with severe neurologic deficit referred to us within a short span of one month. Among them, one had long standing history of back pain while other had none. Both patients were investigated and found to have a sequestrated disc fragment which had dorsally migrated to the epidural space and was causing severe compression of the spinal cord. They underwent laminectomy and removal of the sequestrated fragment. However, they were only partially relieved of their motor and bladder weakness. We present our cases to highlight this rare form of lumbar epidural intervertebral disc migration, as well as enumerate the diagnostic challenges and discuss the differential diagnosis and treatment.

Ewing Sarcoma of the Cervical Epidural Space Presenting with Tetraplegia: Case Report and Review of Literature.

BACKGROUND: Ewing sarcoma (ES) is among the most frequented extremity osseous tumor in childhood. It was first described by James Ewing as diffuse endotheliomas in 1921. The name Ewing sarcoma was coined by Oberling in 1928 as a tribute to the legend who described this disease. ES exists in osseous and extraosseous forms. It shares much of its molecular typing with primitive neuroectodermal tumor (PNET); hence, they are regarded as different ends of the same molecular spectrum. ES, extraosseous ES, PNET, and Askins tumor are the other members of this family termed the Ewing sarcoma family of tumors. Extraosseous ES has been described in various locations of the spine, but its occurrence in the cervical epidural region is uncommon. CASE DESCRIPTION: A 12-year-old child presented to us with neck pain and progressive weakness of all 4 limbs. She was investigated and found to have a highly vascular lesion in the cervical epidural region extending from C2 to the C4 region. Embolization therapy was unsuccessful. She deteriorated and eventually had to undergo emergency surgery to decompress the spinal cord. The lesion was biopsied and diagnosed as extraosseous ES. After radiotherapy and chemotherapy, the patient regained most of the power in her limbs. CONCLUSION: Extraosseous ES is a rare tumor of the cervical cord in this age group. We report this case to highlight the difficulties encountered in the management of this variant.