Capacity building for pediatric neuro-oncology in Pakistan- a project by my child matters program of Foundation S.

Introduction: Initiated in June 2019, this collaborative effort involved 15 public and private sector hospitals in Pakistan. The primary objective was to enhance the capacity for pediatric neuro-oncology (PNO) care, supported by a My Child Matters/Foundation S grant. Methods: We aimed to establish and operate Multidisciplinary Tumor Boards (MTBs) on a national scale, covering 76% of the population (185.7 million people). In response to the COVID-19 pandemic, MTBs transitioned to videoconferencing. Fifteen hospitals with essential infrastructure participated, holding monthly sessions addressing diagnostic and treatment challenges. Patient cases were anonymized for confidentiality. Educational initiatives, originally planned as in-person events, shifted to a virtual format, enabling continued implementation and collaboration despite pandemic constraints. Results: A total of 124 meetings were conducted, addressing 545 cases. To augment knowledge, awareness, and expertise, over 40 longitudinal lectures were organized for healthcare professionals engaged in PNO care. Additionally, two symposia with international collaborators and keynote speakers were also held to raise national awareness. The project achieved significant milestones, including the development of standardized national treatment protocols for low-grade glioma, medulloblastoma, and high-grade glioma. Further protocols are currently under development. Notably, Pakistan's first pediatric neuro-oncology fellowship program was launched, producing two graduates and increasing the number of trained pediatric neuro-oncologists in the country to three. Discussion: The initiative exemplifies the potential for capacity building in PNO within low-middle income countries. Success is attributed to intra-national twinning programs, emphasizing collaborative efforts. Efforts are underway to establish a national case registry for PNO, ensuring a comprehensive and organized approach to monitoring and managing cases. This collaborative initiative, supported by the My Child Matters/Foundation S grant, showcases the success of capacity building in pediatric neuro-oncology in low-middle income countries. The establishment of treatment protocols, fellowship programs, and regional tumor boards highlights the potential for sustainable improvements in PNO care.

Predictors of neurocognition outcomes in children and young people with primary brain tumor presenting to tertiary care hospitals of Karachi, Pakistan: a prospective cohort study.

INTRODUCTION: Primary brain tumors are a common cause of morbidity and mortality in children and young people (CYP) globally. Impaired neurocognitive function is a potential severe consequence in primary brain tumor (PBT) survivors. There are no in-depth studies from low- and middle-income countries (LMICs) to inform management and follow-up. The research questions of this study were as follows: Are the sociodemographic factors (lower age of CYP, female gender, low socioeconomic status, low parental education), disease-related factors (high grade of tumor, presence of seizures, presence of hydrocephalous), and treatment-related factors (adjuvant therapy, no surgical intervention, post-treatment seizures, placement of shunts) associated with decline in neurcognition outcomes 12 months post-treatment in CYP with PBTs? METHODS: A prospective cohort study was conducted from November 2020 to July 2023 at the Aga Khan University Hospital and Jinnah Postgraduate Medical Centre, tertiary care hospitals in Karachi, Pakistan. All CYP aged 5 to 21 years with a newly diagnosed PBTs were eligible. The neurocognition assessment was undertaken by a psychologist at two points, i.e., pre-treatment and at 12 months post-treatment using validated tools. The verbal intelligence was assessed by Slosson Intelligence tool, revised 3rd edition (SIT-R3), perceptual reasoning by Raven's Progressive Matrices (RPM), and the Processing Speed Index by Wechsler Intelligence Scale (WISC V) and Wechsler Adult Intelligence Scale (WAIS-IV). The data were analyzed by STATA version 12 software. Generalized estimating equation (GEE) was used to determine the factors associated with the mean change in 12 months post-treatment verbal and non-verbal neurocognition scores. Unadjusted and adjusted beta coefficients with their 95% confidence intervals were reported. RESULTS: A total of 48 CYPs with PBTs were enrolled, 23 (48%) of them were lost to follow-up and 10 (21%) died. The remaining 25 (52%) were reassessed 12 months after treatment. On multivariable analysis, a significant decline in verbal intelligence scores at 12 months was predicted by post-treatment seizures beta = - 20.8 (95% CI, - 38.2, - 3.4), mothers having no formal educational status and lower household monthly income. Similarly, a significant decline in perceptual reasoning scores was also predicted by post-treatment seizures beta = - 10.7 (95% CI, - 20.6, - 0.8), mothers having no formal education and having lower household monthly income. Worsening of processing speed scores at 12 months post-treatment were predicted by tumor histology, post-treatment seizures beta = - 33.9 (95% CI, - 47.7, - 20.0), lower educational status of the mother, and having lower household monthly. However, an improvement was seen in processing speed scores after surgical tumor resection. CONCLUSION: In this novel study, the post-treatment mean change in verbal and non-verbal neurocognition scores was associated with sociodemographic, tumor, and treatment factors. These findings may have potential implications for targeted early psychological screening of higher risk CYP with PBTs. Identification of these predictors may serve as a foundation for developing more cost-effective treatment thereby alleviating the burden of neurocognitive morbidity. However to establish generalizability, future research should prioritize larger-scale, multicountry studies. (Trial registration: ClinicalTrials.gov Identifier: NCT05709522).

The diagnostic accuracy of straight leg raise test in patients more than 60 years of age suffering lumbar disk herniation with low back pain and sciatica.

Objective: To determine the diagnostic accuracy of the SLR test in elderly patients suffering from lumbar disk herniation with sciatica and low back pain, using magnetic resonance imaging (MRI) as the gold standard. Materials and Methods: A cross-sectional study was conducted at Jinnah Postgraduate Medical Center and a total of 120 patients, above 60 years of age, with symptomatic lumbar disk herniation were enrolled. SLR test was performed and the results recorded. MRI of the lumbar spine was undertaken for confirmation of disk herniation. Results: The sensitivity of the SLR test in patients 60 years and older is 33.3%. A decrease in the diagnostic accuracy of the SLR test with an increment in age was also noted. Conclusion: It was found that with an increment in age, there is a steady decline in the diagnostic accuracy of SLR Test.

Comparison of the accuracy of intraoperative lateral fluoroscopy versus postoperative computed tomography in spinal fusions.

Background: This study compared the accuracy of intraoperative lateral fluoroscopic images versus postoperative computed tomography (CT) 3D studies in the treatment of thoracolumbar spinal fusions. Methods: In a tertiary care hospital (study duration 6 months), we compared the use of lateral fluoroscopic images with the postoperative CT scans in 64 patients with thoracic or lumbar fractures undergoing spinal fusions. Results: Out of the 64 patients, 61% were lumbar followed by 39% thoracic fractures. In the lumbar spine, the accuracy of screw placement utilizing lateral fluoroscopy versus postoperative CT 3D was 97.4%, while in thoracic spine, accuracy was reduced to 84.4%. Of the 64 patients, just 4 (6.2%) patients demonstrated lateral pedicle cortex penetration, 1 (1.5%) patient had a medial pedicle cortex breach, while none exhibited anterior vertebral body cortex penetration. Conclusion: This study documented the efficacy of lateral fluoroscopy in intraoperative thoracic and lumbar spinal fixation as confirmed by postoperative CT 3D studies. These findings support the continued use of fluoroscopy rather than CT intraoperatively to lower the risk of radiation exposure to both patients and surgeons.

Outcome of head injury in motorbike riders.

Objective: To determine the impact of helmet wearing on traumatic brain injury. Methods: We analyzed 400 cases of traumatic brain injury (TBI) in motorbike riders with and without helmet, from July 2017 to December 2020 presenting to the neurosurgery department at Jinnah Postgraduate Medical Center (JPMC), Karachi, Pakistan. The medical records were analyzed for CT scan findings, length of hospital stay, complications (mortality and disability), Glasgow Coma Scale (GCS) and Glasgow outcome score (GOS) at time of discharge. Result: A total of 400 patients with head injury due to motorbike accidents were included and all were male patients. They were equally divided into two groups, 200 in Group-A (with helmet) and 200 in Group-B (without helmet). Majority of the unhelmeted patients i.e. 102 (51%), needed admission in the Intensive Care Unit (ICU) compared to 70 (35%) in helmeted. When comparing non-helmeted patients to helmeted patients, the total median length of hospital stay was greater among non-helmeted patients (10 vs 05 days). Mortality was higher among non-helmeted patients seen in 50 (25%) as compared to 14 (7%) in helmeted patients. Overall, the good outcome was observed in 119 (59.5%) patients in Group-A as compared to70 (35%) patients in Group-B while 81 (40.5%) showed bad outcome in Group-A and 130 (64%) in Group-B. The failure to wear a helmet was found to be strongly linked with abnormal neuroimaging more complications, poor outcome and lower GCS on discharge as compared to patients using helmet. Conclusion: Lack of helmet use is linked to abnormal brain imaging, more complications, and a longer stay in the hospital after a head injury.

Ventriculoperitoneal Shunt Surgery for Hydrocephalus: One of the Common Neurosurgical Procedures and Its Related Problems.

Objective This study was conducted to assess the outcome in patients with hydrocephalus who underwent ventriculoperitoneal (VP) shunt surgery. Methods This retrospective study was conducted at the neurosurgery department of a tertiary care hospital. The time frame was three years and five months from January 2017 to May 2020 with a follow-up of six months. Results This study included 1030 patients, out of whom 64.2% were male and 35.8% were female. While the majority of the patients were more than 11 years of age (466), age did not have any significant impact on the outcome of the ventriculoperitoneal shunt surgery. The most common cause of hydrocephalus was congenital (47.6%). A good outcome was seen in 63.4%, mortality was 10.6%, and complications were identified for 25.8%. The underlying pathology had a significant impact on the outcome in our study (p-value < 0.05) where the congenital cause of hydrocephalus showed a better outcome than any other cause. Conclusion Ventriculoperitoneal shunt is a good way to manage hydrocephalus, but there is always a high risk of complications.

Herniating Intradural Disc at Lumbar L4-L5 Level: A Case Report.

Prolapse of intervertebral disc is a common pathology seen in the neurosurgery field but intradural lumbar disc herniation is a rare entity encountered only during the surgical treatment of prolapse. We present a 30-year-old male who reported lower back pain radiating to the right lower limb for the last 2.5 years. The pain started after a brief history of weight lifting. There were no associated motor or sensory deficits. The magnetic resonance imaging of the lumbosacral spine showed prolapse of intervertebral disc at the level of lumbar L4-L5. The patient underwent laminectomy and intradural discectomy of L4-L5. Patient had a smooth post-operative recovery with no neurological deficits. A thorough radiological examination can aid in the pre-operative diagnosis of an intradural lumbar disc herniation.

The Prediction of Outcomes in Patients Admitted With Traumatic Brain Injury Using the Rotterdam Score.

OBJECTIVE: The objective was to use the Rotterdam score, which is based on a CT scan, to assess the outcomes of traumatic brain injury patients. MATERIAL AND METHODS: This research, which included 319 head trauma patients, was carried out at the neurosurgery department of a tertiary care hospital between June 2019 and December 2020. The Rotterdam score was calculated for each patient on the basis of the first CT scan after the head injury. The Glasgow Outcome Score was used to assess the results three months following the injury. RESULTS: In our research, there were 270 male patients (84.6%) and 49 female patients (15.4%). The mean age was 37.4 ± 15.4 years and road traffic accidents were observed in 275 people (86.2%). Severe traumatic brain injury (TBI) was seen in 123 patients (38.6%). The most common Rotterdam score was 2 in 86 (27.0%) patients, while it was score 3 in 72 (22.6%), score 4 in 59 (18.5%), score 5 in 41 (12.9%), score 1 in 31 (9.7%) and score 6 in 29 (9.1%). The mortality rate was 33.5% in our patients and good recovery was seen in 150 (47.0%) patients. CONCLUSION: The Rotterdam score is a useful tool to evaluate and predict outcomes in head trauma patients.

Critical Assessment of Various Neurosurgery Training Programs of Pakistan.

AIM: To assess the real challenges faced by neurosurgery residents in developing countries with limited resources and massive workload. MATERIAL AND METHODS: This is a cross-sectional study based on the questionnaire filled by the neurosurgery trainees in Pakistan directed at their training, stress factors, surgical competency, research interest, job satisfaction, and future endeavors. RESULTS: A total of 75 neurosurgery residents participated in study; 73.3% were male. About 61.3% were working for more than 72 hours per week. Average sleeping hours per day were less than 7 hours for 92% of trainees. Only 78.6% were able to receive teaching sessions for at least once a week or more. Practical handling of neurosurgical gadgets like microscope and endoscope was never experienced by 26.7% and 18.7%, respectively. Even the senior most residents were able to perform only 41.08% of their surgeries independently. Financial support was only acceptable to 21.3%, and 60.9% want to leave the country upon training completion. CONCLUSION: The training programs in the developing countries need critical changes to provide favorable learning conditions with availability of appropriate surgical tools, structural changes of training programs, development of research interest, and improvement on the socioeconomic needs of the trainee.

Outcome of diffuse axonal injury in moderate and severe traumatic brain injury.

BACKGROUND: Diffuse axonal injury (DAI) is a common presentation in neurotrauma. Prognosis is variable but can be dependent on the initial presentation of the patient. In our study, we evaluated the outcome of diffuse axonal injury. METHODS: This study was conducted at a tertiary care center from September 2018 to December 2019 and included 133 adult patients with moderate or severe head injury (GCS ≤ 12) diagnosed to have the DAI on the basis of MRI. At 3 months, the result was assessed using the Extended Glasgow Outcome Scale (GOS-E). RESULTS: There were a total of 97 (72.9%) males and 36 (27.1%) females with an average age of 32.4 ± 10 years with a mean GCS of 9 at admission. The most common mode of head trauma was road traffic accidents (RTAs) in 51.9% of patients followed by fall from height in 27.1%. Most patients were admitted with moderate traumatic brain injury (64.7%) and suffered Grade I diffuse axonal injury (41.4%). The average hospital stay was 9 days but majority of patients stayed in hospital for ≤ 11 days. At 3 months, mortality rate was 25.6% and satisfactory outcome observed in 48.1% of patients. The highest mortality was observed in the Grade III DAI. CONCLUSION: We conclude that the severity of the traumatic head injury and the grade of the DAI impact the outcome. Survivors require long-term hospitalization and rehabilitation to improve their chances of recovery.

Outcome of cranial firearm injuries in civilian population based on a novel classification system.

BACKGROUND: Cranial firearm injuries (CFAIs) are expected to be frequent during warfare; however, it is becoming increasingly common among civilian population in our part of the world. These injuries are associated with significant morbidity and mortality in addition to financial loss. The objective of our study is to evaluate the pattern of gunshot injuries to cranium and their outcome. METHODS: The study was conducted on 114 patients presenting with CFAIs to Jinnah Postgraduate Medical Centre, Karachi, Pakistan, between June 2015 and January 2019. Patients were evaluated with respect to age, gender, pattern of injury, Glasgow coma scale on arrival, radiological and clinical assessment, surgical intervention, and Glasgow outcome score measured at 6 months follow-up. RESULTS: Among patients with cranial gunshot, injuries most were males (76.3%). More than 50% patients aged between 18 and 35 years. About 46.5% of patients presented with moderate traumatic brain injury commonly involving the temporal lobe (36.8%). Of total 114 patients, 84.2% were managed conservatively but wound debridement was done in all patients. At 6 months, the overall mortality in our patients was 33.3%. Patients with good outcome (GOS 4 and 5) were 30.7% and 35.9% patients had bad outcome (GOS 2 and 3). Complication rate was 14.9% and the most common complication was disseminated intravascular coagulation in 5.2%. CONCLUSION: Surgical intervention has no significant benefit over conservative management on long-term mortality and should be limited to patients with large intracranial hematomas and intraventricular hematomas causing hydrocephalus.

Risk factors, presentation and outcome of meningomyelocele repair.

OBJECTIVE: To determine the risk factors, presentation and outcome of meningomyelocele repair. METHODS: We reviewed 150 cases operated for meningomyelocele (MMC) at Jinnah Postgraduate Medical Centre Karachi between May 2015 and May 2018. Data of infants operated for MMC repair was extracted including socioeconomic status, maternal folate intake during pregnancy, head circumference, location and width of the defect, accompanying bladder and limb anomalies and treatments administered. Patients were followed up for a mean period of six months. RESULTS: A total of 150 children were evaluated, out of which there were 83(55.3%) males and 67(44.7%) females. All belonged to low socio economic group and prenatal maternal folate intake as risk factor was positive in 103(68.7%) cases. Mean head circumference was 37.4 cm (range, 30.7 to 50 cm). Based on their location, 83(55%) of the defects were lumbosacral, 38(25.4%) were lumbar, 16(10.7%) were thoraco lumbar, 10(6.7%) were thoracic and three (2%) were cervical. Mean size of the meningomyelocele sac was 4.3 cm×5.6 cm (range, 1cm×2 cm to 11cm×8.4cm) and 21(14%) of the babies had a skin defect requiring flap. According to accompanying anomalies, 98(65.3%) of the babies had hydrocephalus, 13(9%) had club foot, four (2.7%) had diastematomyelia and three (2%) had tethered cord. Eighty seven (58%) patients had neurological deficit pre operatively and eight (5.4%) patients with normal power deteriorated after surgery out of which five (3.3%) developed paraplegia and three (2%) developed paraparesis. CSF leak was the major complication encountered in 16(11%) followed by meningitis in seven (5%), while the overall mortality was four (2.6%). CONCLUSION: The practice of periconceptional folic acid supplementation is essential to reduce the prevalence of neural tube defects (NTDs) in the developing world. Improved maternal nutrition with access to quality antenatal care is vital to decrease the prevalence and health burden.

Surgical Outcome of Decompression and Fixation of Degenerative Lumbosacral Spondylolisthesis Surgery in Pakistani Population.

Background Spondylolisthesis is characterized by the slipping of one vertebra, compared with the underlying one, due to structural and degenerative changes. Its origin is multifactorial which includes disc degeneration, facet joint anatomic orientation, iliolumbar configuration, and ligament hyperlaxity. The most common operative treatment is decompression and may require an individualized surgical plan. However, only decompression may progress the slippage which can result in pain or recurrence of neurological complaints. Therefore, lumbar fusion and fixation are considered appropriate to stabilise the spine and prevent delayed deterioration. The aim of our study was to find out the outcome of posterior decompression, with reduction and fixation of lumbosacral spondylolisthesis by Oswestry Disability Index (ODI) to improve further our results. Methods This study was conducted from July 2013 to February 2017 including 94 patients with lumbosacral spondylolisthesis. The Meyerding classification was used to grade the extent of vertebral slippage. The assessment was done using the ODI. Results There were 50 (53.19%) males and 54 (46.80%) females with a mean age of 44 years ± 10.49 SD. Backache was present in all patients and claudication in 85 (90.42%) patients. There were 10 (10.63%) patients with spondylolisthesis at L3-L4, 36 (38.29%) at L5-S1 and 48 patients (51.06%) at L4-L5 level. In 48 patients with L4-L5 level, 38 (79.16%) were in grade II while six (12.5%) were in grade III. According to the preoperative ODI score, 38 patients were placed in moderate disability, 42 patients were severely disabled while four patients were disabled. Good outcome was achieved in a total of 79 (84.04%) patients. In 40 (42.55%) patients, with complete reduction, the good outcome achieved in 35 (83.33%) while in 22 (23.40%) patients there was no reduction and a good outcome was achieved in 17 (77.27%) patients. In 38 (40.42%) patients with moderate disability, 32 (84.04%) patients had a good outcome. Post-operative cerebrospinal fluid (CSF) leak occurred in five (5.31%) and wound infection in seven (7.44%) patients while there was no mortality. Conclusion Reduction with decompression can have a good outcome in spondylolisthesis, and ODI should be used as a predictor of outcome. It also shows that proper decompression is required and not a complete reduction.

Radiological Parameters to Predict Hemorrhagic Progression of Traumatic Contusional Brain Injury.

INTRODUCTION: Traumatic intracerebral contusion is a frequent factor culminating in death and disability, and its progression relates to unfavorable outcome. We evaluated the radiological factors associated with hemorrhagic progression of contusions (HPC). MATERIALS AND METHODS: Two hundred and forty-six patients were enrolled in this prospective cohort over a period of 1 year. Contusion volume was quantified using the "ABC/2" technique, whereas progression was considered as >30% increase in the initial volume. Univariate and multivariate statistics were used to examine the correlation between the risk factors of interest and HPC. RESULTS: HPC was seen in 110 (44.7%) patients. Binary logistic regression showed in the final adjusted model that multiplicity (relative risk [RR]: 2.24, 95% confidence limit [CL]: 1.00-5.48), bilateral lesions (RR: 2.99, 95% CL: 1.08-8.25), initial volume of contusion (RR: 4.96, 95% CL: 1.87-13.13), frontal location (RR: 1.42, 95% CL: 1.08-3.56), and presence of concomitant intracranial hematoma (extradural-RR: 3.90, 95% CL: 1.51-10.01, subdural-RR: 2.91, 95% CL: 1.26-6.69, and subarachnoid-RR: 2.27, 95% CL: 1.01-5.80) were significantly associated with HPC. The overall mortality was 18.7% and was almost equal among patients with and without HPC. Mortality was significantly associated with Glasgow Coma Scale on admission (adjusted RR: 12.386, 95% CL: 4.789-32.035) and presence of comorbid conditions (adjusted RR: 0.313, 95% CL: 0.114-0.860). CONCLUSION: Initial computed tomography scan is a good predictor of high-risk group for HPC.

Endoscopic Trans-Sphenoidal surgery; Efficacy and response in Pituitary Adenoma.

OBJECTIVES: The purpose of the study was to access the efficacy and response of the endoscopic transsphenoidal surgery in pituitary adenomas. METHODS: It was descriptive case study, conducted at Neurosurgery Department in collaboration with the Endocrine Unit (Medical Unit-II) Of Jinnah Post Graduate Medical Center Karachi from January 2015 to July 2017. Patients with sellar, supra sellar and para sellar tumors were enrolled in the study. Patients with prolactinoma and recurrent pituitary tumors were excluded. Data was analyzed using SPPS 17. RESULTS: Sixty three patients were included in the study with mean age of 42±8.34 years. There were 40(63.5%) male patients and 23(36.5%) female patients with pituitary adenoma. Headache and visual impairment were the main presentation 55(87.3%) and 56 (88.8%) respectively. Out of all these patients the pituitary adenomas, 51(81%) patients had non secretory and 12 (19%) patients had secretory tumor. Out of these pituitary adenomas 53(84.1%) were macroadenomas and 10(15.9%) were microadenoma. Post operatively marked improvement in the headache was in all 100% patients and vision improved in 54 (96.4%). The most common post operative complication was cerebrospinal fluid (CSF) leak in 10 (15.9%) with 44 (69.8%) having no post complications at all. Mortality was reported to be just 1.6% i-e one patient. CONCLUSION: The endoscopic transsphenoidal approach for pituitary adenoma is the safest procedure with marked improvement in complications and reduction in patient's hospital stay.

Neurosurgical Interventions for Occipital Encephalocele.

AIMS AND OBJECTIVES: The aim of this study is to find the outcome of repair and resection of the occipital encephalocele. STUDY DESIGN: Case series. MATERIALS AND METHODS: The clinical data of fifty consecutive occipital encephalocele patients were retrieved from medical records including operative notes, postoperative follow-up visits, and postsurgical complications were noted for analysis from November 2009 to November 2013 at the Department of Neurosurgery, Jinnah Postgraduate Medical Centre, Karachi, Pakistan. All patients were assessed by computed tomography scan, magnetic resonance imaging brain, and ultrasound when needed. Physician's assessment, physical examination, and his/her questions to the family at follow-up were used as a tool to determine if there was a developmental delay rather than quantitative analysis like hydrocephalus questionnaires. Patients who developed complications and delayed milestone were regarded as no improvement and those who did not develop complications and achieved appropriate milestone were regarded as improved at 18 months follow-up. RESULTS: Of 50 patients, 17 were males and 33 were females. The average age at presentation was 2.4 months. 16 (32%) patients had increased head circumference and hydrocephalus, 2 (4%) had associated Dandy-Walker cyst, 3 (6%) developed developmental delays, and 8 (15%) had a seizure disorder. None of our patients had neurological deficits. The size of the sac ranged from 2 cm × 3 cm to 27 cm × 15 cm. 9 (18%) patients were admitted with the complication of sac rupture and 2 (4%) patients sac ruptured after admission. Only one patient (2%) had a cerebrospinal fluid leak postoperatively that was repaired primarily without patch graft or dura seal while 4 (8%) developed hydrocephalus after repair of the sac which was treated with placement of ventriculoperitoneal shunt. One (2%) patient did not recover from anesthesia and expired. CONCLUSION: Encephalocele is commonly seen in the practice of neurosurgery in the world as well as in Pakistan. Modern neuroimaging, neurosurgical techniques, and neonatal neurological intensive care have greatly improved morbidity and mortality in the care of encephalocele.

Modern Microsurgical Resection of Olfactory Groove Meningiomas by Classical Bicoronal Subfrontal Approach without Orbital Osteotomies.

BACKGROUND: The olfactory groove meningioma has always been surgically challenging. The common microscopic surgical procedures exercised involve modification of pterional or sub-frontal approaches with or without orbital osteotomies. However, we believe that orbital osteotomies are not mandatory to achieve gross total resection. Hence, this study was performed to evaluate the surgical outcomes of olfactory groove meningioma with bicoronal sub frontal approach but without orbital osteotomies. MATERIALS AND METHODS: The study was performed by reviewing the medical charts, neuroimaging data, and follow-up data of 19 patients who were treated micro surgically for olfactory groove meningioma without orbital osteotomies in our department. Mean overall follow up period of our study was 5 years. Statistical analysis was done by means of IBM SPSS Software version 19. RESULTS: Nineteen patients (1 male and 18 female patients, with an age range of 35-67 years; average age of patients' 51±7.5 years) of OGM were managed in our department. All patients were evaluated by MRI Brain with and without Gadolinium, CTA, CT Scan both axial and Coronal sequences. Most common symptom reported was head ache (80%), others include; urinary incontinence (26%), seizures (78%), decreased visual acuity (79%), papilledema (74%), personality changes (68%) and olfactory loss was reported in 57% of the patients. Post-operative complications include; CSF accumulation (5%), hematoma at tumor bed (10%), skin infection (5%) and mild post-operative brain edema (26%). Mortality rate was 5%. During 5 years of follow-up, we recorded one recurrence which was after 26 months and successfully removed in reoperation. CONCLUSION: Bi-coronal sub frontal approach appears to be an excellent technique for Olfactory Meningioma removal as practiced by most neurosurgeons. Nevertheless, it is not mandatory to carry out orbital osteotomy to acquire optimal surgical outcome as is advocated by some Authors.

Impact of depressed skull fracture surgery on outcome of head injury patients.

OBJECTIVE: To assess outcomes in surgically managed patients with depressed skull fractures and associated moderate to severe head injury. METHODS: The study was conducted in the Department of Neurosurgery Jinnah Postgraduate Medical Centre, Karachi, from January 2016 to December 2017. We analyzed 90 patients with depressed skull fracture managed surgically from January 2015 to December 2016. The patients selected for this study belonged to all age groups with clinically palpable depressed skull fracture confirmed by CT brain with bone window. Outcome was assessed by Glasgow outcome score. RESULTS: Total 90 patients were included in the study. Sixty (66.7%) were male and 30 (33.3%) were female with mean age of years 27.58+11.329. Among 90 patients, 38.8% were aged between 21 and 30 years. Road traffic accident was seen in 72 (80%) patients. The commonest site of fracture was frontal region in 50 patients (55.6%). GCS improved post operatively on comparison to preoperative. Five patients expired. CONCLUSION: Depressed skull fracture is common neuro surgical issue. Timely surgical management gives excellent results by decreasing morbidity and mortality.

Intracranial Epidermoid Lesions: our Experience of 38 Cases.

BACKGROUND: The clinical outcome following surgical resection of intracranial epidermoid lesions is not well documented. We describe a case series evaluating the clinical presentation and outcome following surgery in patients diagnosed with these lesions. MATERIALS AND METHODS: A retrospective study conducted over a 4-year period. RESULTS: A total 38 patients who underwent surgery for intracranial epidermoid lesions were identified. Of these, 20 were supertentorial and 18 were infratentorial lesions. 33 patients presented with headache. 10 patients with supratentorial lesions presented with seizures. Patients with suprasellar epidermoid lesions presented with headache and visual problems. 14 of the 18 patients with cerebellopontine angle lesions presented with symptoms of trigeminal neuralgia. Post-operatively, 3 patients with cerebellopontine angle tumors developed facial weakness which was transient in 2 patients but permanent in 1 patient. Visual impairment in patients with suprasellar epidermoid lesions improved post-operatively. Hormonal replacement therapy was required in 2 patients. Recovery of 4 patients was complicated by Cerebrospinal fluid (CSF) leak while meningitis developed in 2 patients. One patient operated for cerebellopontine angle epidermoid died post operatively. CONCLUSIONS: Epidermoid lesions can develop anywhere in the cranial cavity. Like other space occupying lesions they often present with symptoms of raised ICP and with specific neurological deficits depending on location of the tumour. Surgical outcome is excellent with low complication rates.

Outcome of burr-hole aspiration of brain abscess.

OBJECTIVE: To determine the clinical outcome of burr-hole aspiration of brain abscess. METHODS: We analyzed 100 cases of intracranial abscess, treated surgically from January 2015 and October 2016 at Jinnah Postgraduate Medical Centre (JPMC). All patients were treated with burr hole aspiration. Medical records were analyzed for demographics, clinical presentation, predisposing factors, abscess location on imaging and clinical outcomes were charted. RESULTS: The study included 100 patients with 73 (73%) males and 27 (27%) females with a mean age of 36.69±10.96 years. Mean duration of signs and symptoms was 8.50±4.2 days. The most common presenting complaint was altered sensorium in 70 (70%) patients and commonest source of infection was otitis media seen in 27 patients (27%). The GCS on presentation was 13 in 57 (57%) cases. The parietal region was the most common site in 43 patients (43%), followed by frontal region in 33 patients (33%). Complete resolution of abscess with recovery of preoperative neuro-deficit was seen in 77 (77%) patients and recovery with major neuro-deficit was observed in 10 (10%) cases while 13 (13%) patients expired. CONCLUSION: Early diagnosis, optimum follow-up and timely burr-hole aspiration are the keys in the proper management of brain abscess.