Clinical Characteristics and Outcome of Patients with Multiple Intracranial Aneurysms from a University Hospital in Nepal.

Objective The risk factors, management strategies, and outcomes of patients with multiple intracranial aneurysms (MIAs) are different compared with that of patients with a single aneurysm. Data are scarce regarding patients with MIAs from developing countries. The objective of this study was to describe the clinical characteristics, management strategies, and outcomes of patients treated microsurgically from Nepal. Methods The clinical records of patients confirmed to have MIAs and microsurgically clipped between July 2014 and December 2019 were retrospectively reviewed. Data on demographic and clinical characteristics, computed tomography findings, multiplicity and location of aneurysms, management strategies, and the 1-year outcome were abstracted and analyzed. Results Two hundred cerebral aneurysms were microsurgically clipped in 170 consecutive patients during the study period. Twenty-six (13.0%) patients harbored 60 aneurysms. The mean age of the patients was 58.5 (43-73) years. Smoking and hypertension were found in 20 (76.9%) and 16 (61.5%) patients, respectively. The majority of patients [17 (65.4%)] were in good grades at presentation. Twenty-one patients had two aneurysms, four had three aneurysms, and one patient had five aneurysms. The middle cerebral artery was the commonest (20) followed by distal anterior cerebral artery (14) and anterior communicating artery (13) involved in multiplicity. A single-stage surgery was performed on 17 patients. Serial clipping was performed in six patients. In three patients, a single aneurysm on the contralateral side was left untreated for various reasons. The favorable outcome was achieved in 23 (88.5%) patients whereas three (11.5%) patients had an unfavorable outcome. One patient died. Conclusion The demographic and clinical characteristics of patients in our series are comparable with those described in the published literature from other countries. With an individualized treatment strategy, an acceptable outcome can be achieved in the majority of the patients.

Marshall Computed Tomography Scoring System in Predicting Early Mortality in Patients with Traumatic Brain Injury.

BACKGROUND: Traumatic brain injury is common neurological emergency worldwide associated with high rates of morbidity and mortality. Marshall scoring system is one of the several scoring systems that uses initial computed tomography findings to predict outcome. This study aims to determine the role of Marshall scoring system in predicting early mortality in patients with Traumatic brain injury in Nepalese patient population. METHODS: Patients admitted with diagnosis of Traumatic brain injury between August 2017 and July 2018 in our institution were studied prospectively. Clinical status of patient was noted and computed tomography scan of head was interpreted according to Marshall scoring system. Patients were monitored during the hospital stay and in-hospital mortality was correlated with different components of Marshall scoring system at discharge. RESULTS: The most common cause of Traumatic brain injury was road traffic accident (45%). Severe Traumatic brain injury was noted in 17% of patients and commonest intracranial mass lesion was contusion (24%). Surgery was performed in 29% of patients. There was significant correlation between increase in Marshall score and mortality (p<0.001). Degree of midline shift (p<0.016), status of basal cisterns (p<0.001), and combination of mass lesions (p=0.005) were independent predictors of early mortality. CONCLUSIONS: Marshall scoring is highly reliable scoring system to predict early mortality in patients with Traumatic brain injury. Degree of midline shift, status of basal cisterns, and combination of mass lesions are independent parameters predicting early mortality in patients with traumatic brain injury.

A case report of aneurysmal subarachnoid hemorrhage in a Young with IgA: A mere co-existence?

INTRODUCTION AND IMPORTANCE: Aneurysmal Subarachnoid hemorrhage (SAH) can be associated with various other conditions like Polycystic kidney disease, Ehler Danlos syndrome, Co-arctation of the aorta, etc. CASE PRESENTATION: Here we have reported a 21-year young lady with IgA nephropathy and aneurysmal SAH managed successfully. CLINICAL FINDINGS AND INVESTIGATIONS: The patient was a known case of IgA nephropathy diagnosed 18 months back from a kidney biopsy. She came to the emergency with a headache and vomiting for 2 weeks. Her initial headache was the worst she has had experienced and then the headache was continuous and not relieved by medications. Then she underwent a noncontrast CT scan of the head which showed Subarachnoid hemorrhage (SAH). INTERVENTIONS AND OUTCOMES: Left pterional craniotomy and microsurgical clipping of left ICA aneurysm performed. The patient was discharged without deficits. RELEVANCE AND IMPACT: Aneurysmal Subarachnoid hemorrhage(SAH) can be due to histopathological changes to the vessels following IgA nephropathy. These correlations could be studied further or else it could be only a mere coincidence.

Temporal Delay in Neurosurgical Patients and Outcome in a Tertiary Care Center in Nepal.

BACKGROUND: Neurosurgery is a field where time from the incident to get treatment is very crucial. In low-income countries, the referral system is not well developed. In our country, a proper referral system is in the initial phase of development. We conducted a study assessing the number of visits a neurosurgery patient made before finally reaching to our center. METHODS: This is a prospective observational study involving seventy patients, conducted at Tribhuvan University Teaching Hospital, Kathmandu, Nepal. Demographic characteristics, neurological diagnosis, and numbers of other centers the patients visited and outcome at discharge and in one month was assessed. RESULTS: Thirty-five (50%) patients were males. Thirty-three (47.1%) patients were admitted due to head injury and 13 (18.5%) were diagnosed with subarachnoid hemorrhage. Surgery was done in 32 (45.7%) patients. Fifty-three (75.7%) patients were transferred from other hospitals. Out of 53 patients, 30 (56.6%) and 17 (32%) had visited to one and two hospitals respectively. Unavailability of the neurosurgery facility was the main reason (77.4%) for the transfer. Overall mortality was 12.9%. The trend for mortality and length of hospital stay was higher in the group who visited other centers before coming to us than those who came directly. CONCLUSIONS: Visiting multiple hospitals where there is no neurosurgical service available is an important reason for delay. There is a need to develop neurosurgical facilities in the different parts of the country along with establishment of an effective referral mechanism.

Major Spinal Surgery Between Two Documented COVID-19 Infections in an Elderly Female: A Case Report.

Documented re-infection of COVID-19 is uncommon and doing a major spinal surgery in an elderly patient right after the recovery from the first event is itself a major undertaking. Re-infection after successful surgery points to the possibility of COVID-19 infection being a post-surgical complication. Here, we report a case of a 72-years-old elderly female who had presented to us with features of COVID-19 infection confirmed by reverse transcription polymerase chain reaction assay and unstable spinal fracture who underwent a pedicle screw fixation for the fracture of the third and fourth thoracic vertebrae after two consecutive negative serology assays. A month after discharge from the hospital, she presented with severe symptoms of COVID-19 again confirmed by two consecutive polymerase chain reaction assays. She was managed conservatively and was discharged without significant respiratory and neurological complications. We described this case in detail in addition to reviewing the pertinent literature.

Recurrent Sacral Chordoma: A Case Report.

Chordoma is a rare and locally aggressive tumor that arises from the notochordal remnants and has an incidence of 0.1/100000 per year. It has a predilection for the axial skeleton and is the most common primary malignant tumor of sacrum. The mainstay of treatment is wide surgical excision but there is a risk of recurrence due to the infiltrating nature of the tumor. Here, we report a case of a 56-years male who complained of pain over his sacral region for the past two years along with episodic urinary symptoms, constipation, and weakness of both legs. Seven years after undergoing surgery and radiotherapy for his sacral chordoma, he was diagnosed with recurrent sacral chordoma and planned for reoperation. Subtotal excision of the chordoma was done which significantly alleviated his symptoms postoperatively. Timely intervention helps to improve the quality of life in patients with either primary or recurrent sacral chordomas.