RESUMO
OBJECTIVES: The arachnoid often bulges prematurely during surgical excision of large pituitary tumors obscuring the deeper regions and crevices preventing total excision. Pushing the arachnoid may not be helpful and may tear it inadvertently and extensively leading to complications. We have described controlled arachnoid opening in large pituitary macroadenomas during the final stages of excision to gain access to the hidden portions and compared our results to the conventional technique. PATIENTS AND METHODS: Patients with pituitary macroadenoma of Hardy's III and KNOSP II in whom arachnoid had bulged prematurely were considered for study. They were grouped temporally. In first group (n = 12), the arachnoid was pushed to retrieve the tumor and in the second group (n = 10) it was punctured to aid resection. The extent of resection was assessed on postoperative scans, and complications in both groups, were noted. RESULTS: In the first group where arachnoid was pushed to retrieve tumor, Gross Total Resection (GTR) could be achieved in 5 patients. Inadvertent large arachnoid tear occurred in 3 patients of which, 2 developed CSF Rhinorrhoea. No patient had neurovascular injury.In the second group, GTR could be achieved in all without any added complications. CONCLUSION: Deliberate needle puncture and controlled drainage of CSF from arachnoid that bulges prematurely while endoscopic Transsphenoidal surgery for large pituitary tumors is a safe and effective method to gain access to the hidden portions of tumor to achieve GTR.
Assuntos
Rinorreia de Líquido Cefalorraquidiano , Neoplasias Hipofisárias , Humanos , Neoplasias Hipofisárias/diagnóstico por imagem , Neoplasias Hipofisárias/cirurgia , Neoplasias Hipofisárias/patologia , Estudos Retrospectivos , Endoscopia/métodos , Aracnoide-Máter/cirurgia , Resultado do TratamentoRESUMO
BACKGROUND: To limit the role of bilateral inferior petrosal sinus sampling (BIPSS) in distinguishing between Cushing disease (CD) and ectopic Cushing syndrome (ECS), recent reports have proposed a noninvasive approach based on a combination of biochemical testing and radiological imaging as an alternative to the conventional invasive strategy (CIS). However, this strategy requires further validation. The current study aimed to evaluate 2 limited invasive protocols (LIP-1 and LIP-2) in limiting the role of BIPSS while maintaining a diagnostic accuracy similar to that of CIS. METHODS: This was a single-center study conducted on individuals with corticotropin-dependent Cushing syndrome. The LIPs were based on performing high-dose dexamethasone suppression (>50% cut-off in first [LIP-1] and >80% in second [LIP-2]) and magnetic resonance imaging of the sella in all individuals and selective use of computed tomography of the chest and abdomen before BIPSS. These LIPs were evaluated for limiting the use of BIPSS, their accuracy, and cost in comparison to CIS. RESULTS: Of the 206 individuals, 114 (97 of CD and 21 of ECS) were eligible for the current study. Using LIP-1, LIP-2, and CIS, BIPSS could have been avoided in 62.3%, 35.9%, and 25.4% of individuals, respectively. The positive predictive value for CD using LIP-1 and LIP-2 was 98.9% and 100%, respectively. The cost per patient evaluated using LIP-1, LIP-2, and CIS was $602.21, $966.81, and $1107.78, respectively. CONCLUSION: LIPs represent an equally accurate, less invasive, and more cost-effective alternative to the CIS for distinguishing between CD and ECS.
Assuntos
Síndrome de Cushing , Hipersecreção Hipofisária de ACTH , Hormônio Adrenocorticotrópico , Síndrome de Cushing/diagnóstico , Diagnóstico Diferencial , Humanos , Imageamento por Ressonância Magnética , Amostragem do Seio Petroso/métodos , Hipersecreção Hipofisária de ACTH/diagnóstico por imagemRESUMO
Despite widespread popularity of navigation and angled endoscopes in endonasal endoscopy, there are hardly few studies on their efficacy with the extent of resection or retreatment. This is probably the first study to assess the independent impact of these adjuncts among pituitary tumors. Patients with pituitary tumors undergoing endonasal endoscopy were prospectively studied for their demographics, clinico-radiological features, intraoperative use of navigation, and angled endoscopes, in relation to gross total resection (GTR), near total resection (NTR), endocrine remission, and retreatment. Pertinent statistical analyses were performed. Among a total of 139 patients, navigation and angled endoscopes could be used in 54 and 48 patients, respectively, depending upon their availability rather than chosen as per the case. There was no significant difference in baseline characteristics in relation to their use. The surgeon's perception of immediate benefit was noted among 51.9% while using navigation. The use of angled endoscopes towards the end of resection could help with additional tumor removal in 62.5% of patients. Overall, the use of navigation resulted in a significantly higher GTR (80.8% vs. 59.7%, OR 2.83, p = 0.01), a higher GTR/NTR (86.5% vs. 70.8%, OR 2.65, p = 0.04), and a lower retreatment rate (7.7% vs. 20.8%, OR 3.15, p = 0.05) than the others. In functioning tumors with cavernous sinus invasion, navigation had significantly increased remission rates (69.2% vs. 0%, p = 0.03). The use of angled endoscopes yielded a significantly higher GTR/NTR (91.7% vs. 70.6%, p = 0.04) and a lower retreatment rate (0% vs. 15.7%, p = 0.05) among only non-functioning adenomas. In multivariate analyses, the use of neuronavigation had a significant association with both GTR and retreatment rates (p values 0.005 and 0.02 respectively), independent of other confounding factors. The elective intraoperative use of navigation has a significant independent impact on the extent of resection and retreatment overall. While navigation results in better remission rates among functioning tumors with cavernous sinus invasion, angled endoscopy has a significant association with surgical outcomes in non-functioning tumors.
Assuntos
Neoplasias Hipofisárias , Endoscópios , Endoscopia , Humanos , Neoplasias Hipofisárias/cirurgia , Estudos Prospectivos , Resultado do TratamentoRESUMO
BACKGROUND: The COVID19 lockdown has altered the dynamics of living. Its collateral fallout on head injury care has not been studied in detail, especially from low- and middle-income countries, possibly overwhelmed more than developed nations. Here, we analyze the effects of COVID19 restrictions on head injury patients in a high-volume Indian referral trauma center. METHODS: From the prospective trauma registry, clinico-epidemiological and radiological parameters of patients managed during 190 days before and 190 days during COVID19 phases were studied. As an indicator of care, the inpatient mortality of patients with severe HI was also compared with appropriate statistical analyses. RESULTS: Of the total 3372 patients, there were 83 head injury admissions per week before COVID19 restrictions, which decreased to 33 every week (60% drop) during the lock phases and stabilized at 46 per week during the unlock phases. COVID19 restrictions caused a significant increase in the proportion of patients arriving directly without resuscitation at peripheral centers and later than 6 h of injury. Though the most common mechanism was vehicular, a relative increase in the proportion of assaults was noted during COVID19. There was no change in the distribution of mild, moderate, and severe injuries. Despite a decrease in the percentage of patients with systemic illnesses, severe head injury mortality was significantly more during the lock phases than before COVID19 (59% vs. 47%, p = 0.02). CONCLUSIONS: COVID19 restrictions have amplified the already delayed admission among patients of head injury from north-west India. The severe head injury mortality was significantly greater during lock phases than before COVID19, highlighting the collateral fallout of lockdown. Pandemic control measures in the future should not ignore the concerns of trauma emergency care.
Assuntos
COVID-19/epidemiologia , Traumatismos Craniocerebrais/epidemiologia , Quarentena/estatística & dados numéricos , Adulto , COVID-19/prevenção & controle , Feminino , Hospitalização/estatística & dados numéricos , Humanos , Índia , Masculino , Pessoa de Meia-Idade , Centros de Traumatologia/estatística & dados numéricosRESUMO
BACKGROUND: Although head injury (HI) from low- and middle-income countries (LMIC) heavily contributes to the global disease burden, studies are disproportionately less from this part of the world. Knowing the different epidemiological characteristics from high-income nations can target appropriate prevention strategies. This study aims to provide a comprehensive overview of the clinico-epidemiological data of HI patients, focusing on the existing challenges with possible solutions from a developing nation's perspective. METHODS: This is a prospective, registry-based, observational study of HI in an Indian tertiary trauma-care center over 4 years. Various clinico-epidemiological parameters, risk factors, and imaging spectrum were analyzed in a multivariate model to identify the challenges faced by LMIC and discuss pragmatic solutions. RESULTS: The study included a large-volume cohort of 14,888 patients. Notably, half of these patients belonged to mild HI, despite most were referred (90.3%) cases. Only one-third (30.8%) had severe HI. Less than a third reached us within 6 h of injury. Road traffic accidents (RTA) accounted for most injuries (61.1%), especially in the young (70.9%). Higher age, males, RTA, helmet non-usage, drunken driving, systemic injuries, and specific imaging features had an independent association with injury severity. CONCLUSIONS: The study represents the much-needed, large-volume, epidemiological profile of HI from an LMIC, highlighting the suboptimal utilization of peripheral healthcare systems. Strengthening and integrating these facilities with the tertiary centers in a hub and enhanced spoke model, task sharing design, and efficient back-referrals promise effective neurotrauma care while avoiding overburden in the tertiary centers. Better implementation of road safety laws also has the potential to reduce the burden of HI.
Assuntos
Traumatismos Craniocerebrais , Centros de Traumatologia , Acidentes de Trânsito , Estudos de Coortes , Traumatismos Craniocerebrais/epidemiologia , Traumatismos Craniocerebrais/terapia , Humanos , Masculino , Estudos Observacionais como Assunto , Estudos Prospectivos , Sistema de RegistrosRESUMO
AIM: To test the effectiveness of nurse-led dietary diabetes insipidus (DI) bundle on the severity of postoperative fluid imbalance in pituitary region tumours. DESIGN: Blinded randomized controlled trial. METHODS: Patients aged 18-65 operated for sellar-suprasellar tumours in an Indian tertiary care centre were enrolled through total enumeration sampling and underwent randomization with allocation concealment during Sep 2018-Feb 2019. Pre-operative DI, postoperative ventilation, renal failure or decompensated diabetes mellitus were excluded. Patients in the intervention group received a nurse-led DI bundle (validated by three Delphi rounds) with four dietary components: intake of only water during thirst and avoidance of the following-added salt, high-protein foods and caffeinated drinks. Treating clinicians and the investigator assessing outcome were blinded about enrolment. Urine output, serum sodium, vasopressin requirement and hospital stay were assessed as primary outcomes. The outcome measures were monitored daily till the 6th postoperative day. Analyses were performed on 'intention-to-treat' basis, irrespective of compliance. Independent t-test and Chi-square test were used. RESULTS: Of the initial 63 patients, 50 fulfilling criteria were randomized to two groups and assessed over six days yielding 150 patient-days per group. There were no significant baseline differences between groups. The mean daily urine output was significantly lower in the DI bundle group than in control, both overall and among endonasal operated pituitary adenomas [3000.09(462.7) vs. 4095.71(896.4)ml & 2987.14(419.5) vs. 4064.73(1051)ml], with the greatest difference on the second postoperative day. Though hypernatraemia in controls became most prominent during days 2-3 and resolved in a week, it was significantly lower in the intervention group (12.7% vs. 30.7% overall, 11.4% vs. 29.4% endonasal adenomas). The need for vasopressin analogues and hospital stay were also significantly lower with DI bundle (p < 0.001). CONCLUSION: This is probably the first ever report of dietary DI bundle among operated pituitary patients, which seem to flatten the DI trend with significant benefits in polyuria, hypernatraemia, vasopressin requirement and hospital stay. TRIAL REGISTRATION: CTRI/2018/07/015127 of ICMR. IMPACT: The nurse-led dietary DI bundle has effectively reduced the severity of DI among operated pituitary patients with significant benefits in polyuria, hypernatraemia, vasopressin requirement and hospital stay. Its implementation is simple and easy to carry out, especially in resource-constrained institutions, where continuous monitoring and repeated serum sodium estimation are difficult.
Assuntos
Adenoma , Diabetes Insípido , Diabetes Mellitus , Neoplasias Hipofisárias , Adenoma/cirurgia , Diabetes Insípido/tratamento farmacológico , Humanos , Neoplasias Hipofisárias/cirurgia , Período Pós-OperatórioRESUMO
OBJECTIVE: COVID-19 has affected surgical practice globally. Treating neurosurgical patients with the restrictions imposed by the pandemic is challenging in institutions with shared patient areas. The present study was performed to assess the changing patterns of neurosurgical cases, the efficacy of repeated testing before surgery, and the prevalence of COVID-19 in asymptomatic neurosurgical inpatients. METHODS: Cases of non-trauma-related neurosurgical patients treated at the Postgraduate Institute of Medical Education and Research (PGIMER) before and during the COVID-19 pandemic were reviewed. During the pandemic, all patients underwent a nasopharyngeal swab reverse transcription-polymerase chain reaction test to detect COVID-19 at admission. Patients who needed immediate intervention were surgically treated following a single COVID-19 test, while stable patients who initially tested negative for COVID-19 were subjected to repeated testing at least 5 days after the first test and within 48 hours prior to the planned surgery. The COVID-19 positivity rate was compared with the local period prevalence. The number of patients who tested positive at the second test, following a negative first test, was used to determine the probable number of people who could have become infected during the surgical procedure without second testing. RESULTS: Of the total 1769 non-trauma-related neurosurgical patients included in this study, a mean of 337.2 patients underwent surgery per month before COVID-19, while a mean of 184.2 patients (54.6% of pre-COVID-19 capacity) underwent surgery per month during the pandemic period, when COVID-19 cases were on the rise in India. There was a significant increase in the proportion of patients undergoing surgery for a ruptured aneurysm, stroke, hydrocephalus, and cerebellar tumors, while the number of patients seeking surgery for chronic benign diseases declined. At the first COVID-19 test, 4 patients (0.48%) tested were found to have the disease, a proportion 3.7 times greater than that found in the local community. An additional 5 patients tested positive at the time of the second COVID-19 test, resulting in an overall inpatient period prevalence of 1%, in contrast to a 0.2% national cumulative caseload. It is possible that COVID-19 was prevented in approximately 67.4 people every month by using double testing. CONCLUSIONS: COVID-19 has changed the pattern of neurosurgical procedures, with acute cases dominating the practice. Despite the fact that the pandemic has not yet reached its peak in India, COVID-19 has been detected 3.7 times more often in asymptomatic neurosurgical inpatients than in the local community, even with single testing. Double testing displays an incremental value by disclosing COVID-19 overall in 1 in 100 inpatients and thus averting its spread through neurosurgical services.
Assuntos
Teste de Ácido Nucleico para COVID-19/tendências , COVID-19/diagnóstico , COVID-19/epidemiologia , Hospitalização/tendências , Procedimentos Neurocirúrgicos/tendências , Adolescente , Adulto , Idoso , Teste de Ácido Nucleico para COVID-19/normas , Pré-Escolar , Feminino , Humanos , Índia/epidemiologia , Masculino , Pessoa de Meia-Idade , Procedimentos Neurocirúrgicos/normas , Prevalência , Resultado do TratamentoRESUMO
Brain abscess remains a life-threatening condition. Here, we are reporting a case of brain abscess due to Fusobacterium nucleatum in a previously known case of Ebstein anomaly. A 44-year-old male presented with the complaints of headache, and fever. Cerebral imaging revealed parieto-occipital (PO) abscess. The abscess was drained and culture showed growth of Fusobacterium nucleatum. This report illustrates the importance of considering anaerobes as the cause of brain abscess, underscores the usefulness of MALDI, which facilitated the selection of appropriate and prompt adjuvant antibiotic therapy and a favourable outcome.
Assuntos
Abscesso Encefálico/diagnóstico , Abscesso Encefálico/etiologia , Anomalia de Ebstein/complicações , Infecções por Fusobacterium/diagnóstico , Infecções por Fusobacterium/etiologia , Fusobacterium , Adulto , Biomarcadores , Encéfalo/anormalidades , Encéfalo/diagnóstico por imagem , Encéfalo/patologia , Abscesso Encefálico/terapia , Terapia Combinada , Embolia Paradoxal/diagnóstico , Embolia Paradoxal/etiologia , Infecções por Fusobacterium/terapia , Humanos , Masculino , Tomografia Computadorizada por Raios X , Resultado do TratamentoRESUMO
OBJECTIVE: To prospectively compare positron emission tomography-computed tomography (PET-CT) with conventional magnetic resonance imaging (MRI) and FNAC for diagnosis of non- traumatic vertebral lesions fracture in countries like India where tuberculosis is endemic. METHODS: Fifty four patients with non-traumatic spontaneous vertebral lesions were prospectively studied. All patients underwent CEMRI focusing on the spinal lesions, whole-body PET-CT and FNAC.Results were then analysed and compared with final diagnosis obtained either by FNAC or clinical follow up. RESULTS: Out of total 54 patients, FNAC from the spinal lesion could establish diagnosis in 36 patients (26 TB, 1 Fungal and 9 tumors). Of the remaining 18 patients, diagnosis could be established in 7 utilizing FNAC from other sites as dictated by PET-CT. In the remanining11 patients, the diagnosis and management was decided on the concordance of MRI and PET-CT. CONCLUSION: All three investigations have their own advantages and pitfalls and they complement each other in reaching the final diagnosis. MRI has a better pick up rate (than PET-CT) for inflammatory lesions. PET-CT on the other hand has better sensitivity for malignant vertebral disease. Diagnosis was established if FNAC was conclusive. In cases where FNAC was inconclusive, an additional 38.9% patients' diagnosis could be established by FNAC from other sites of involvement as dictated by PET-CT. This was an incremental utility of PET-CT. When even this fails, there were two possible scenarios-MRI and PET-CT in concordance with each other. In such a scenario, the combined report of MRI and PET-CT was relied upon. The last sub group (where MRI and PET-CT were discordant and FNAC was inconclusive) still remains achilles' heel. Wide bore biopsy may help in establishing diagnosis in such group.
Assuntos
Doenças da Coluna Vertebral/diagnóstico , Adulto , Idoso , Algoritmos , Biópsia por Agulha Fina/normas , Feminino , Humanos , Índia , Imageamento por Ressonância Magnética/normas , Masculino , Pessoa de Meia-Idade , Micoses/diagnóstico , Tomografia por Emissão de Pósitrons combinada à Tomografia Computadorizada/normas , Estudos Prospectivos , Neoplasias da Coluna Vertebral/diagnóstico , Tuberculose da Coluna Vertebral/diagnósticoRESUMO
Background and Purpose- Though reports suggest decreasing fatality rates of subarachnoid hemorrhage with time, trends in outcome are not reported much especially from developing countries. This study was to analyze changes in outcome across 2 decades and elucidate probable factors. Methods- Prospective databases during 1996 to 2015 were reviewed for neurological outcome at 3 months in relation to demographics, Hunt and Hess grade, Fisher grade, and definitive treatment; and compared between 2 decades, contrasted by establishment of intensive care unit with continuous monitoring and other advancements. Univariate and multivariate analyses were performed. Results- Of the total 2039 patients, 1035 were managed in the former and 1004 in the recent decades. Compared with the former decade, there is delayed age at presentation (46 versus 49 years, P<0.001), poorer Fisher grades (81% versus 87%, P<0.001), and more patients with Hunt and Hess grade 2 (24% versus 39%, P<0.001) in the recent decade. While all patients in databases of the former decade had undergone clipping, 6% in the recent decade underwent coiling. 11% in the recent decade could not undergo definitive treatment. Despite this, there was significantly higher overall favorable outcome (50% versus 60%; odds ratio, 1.5; P<0.001) in recent decade. Favorable outcome of surgical clipping per se improved significantly from 50% to 67% (odds ratio 2.0; P<0.001). Though the improvement was across subgroups, it was more marked among Hunt and Hess grade 3 and Fisher grades 3 and 4. In multivariate analyses, both overall outcome (adjusted odds ratio, 1.7; 95% CI, 1.4-2.1; P<0.001) and surgical outcome (adjusted odds ratio, 1.8; 95% CI, 1.5-2.2; P<0.001) were significantly better in recent decade, independent of known prognostic factors. Conclusions- This is probably the first report to show independent improvement in outcome of subarachnoid hemorrhage with betterment in neurosurgical services from developing country. Dedicated intensive care unit care and focused management protocols could be the likely causes for improvement. Resource-constrained institutions may target patients in Hunt and Hess grade 3 and Fisher grades 3 and 4 for optimal intensive care unit utilization.
Assuntos
Países em Desenvolvimento , Procedimentos Neurocirúrgicos/normas , Hemorragia Subaracnóidea/terapia , Adulto , Bases de Dados Factuais , Feminino , Hidratação/métodos , Escala de Resultado de Glasgow , Humanos , Índia , Pressão Intracraniana , Masculino , Pessoa de Meia-Idade , Monitorização Fisiológica , Análise Multivariada , Procedimentos Neurocirúrgicos/tendências , Nimodipina/uso terapêutico , Razão de Chances , Avaliação de Resultados em Cuidados de Saúde , Qualidade da Assistência à Saúde , Resultado do Tratamento , Vasodilatadores/uso terapêuticoRESUMO
BACKGROUND: Establishment of a reliable and rapid diagnosis is of paramount importance in spinal tuberculosis. The available gadgetry of investigations, such as AFB smear, culture of Mycobacterium tuberculosis, and Uniplex PCR, suffers from a lack of adequate sensitivity and/or a lack of rapidity. Therefore, many times a diagnosis is made either very late in the disease process or sometimes empirical therapy has to be started because a definite diagnosis could not be made. All of these are not ideal situations for a clinician. The present study was done with the aim to establish a rapid and reliable diagnosis of M. tuberculosis infection. This was established by identifying M. tuberculosis genes. METHODS: The study was done on nine consecutive patients who presented with non-traumatic spontaneous vertebral compression collapse. CT-guided aspirate from the involved vertebra was subjected to Multiplex PCR (MPCR) using three primers: IS6110, protein b, and MPB 64. The aspirate was also subjected to smear and culture. The results of MPCR were compared with the final diagnosis. RESULTS: Seven out of nine patients had a final diagnosis of tuberculosis. MPCR was positive in six of these seven patients, thus showing sensitivity of 85.7% and specificity of 100%. Results of MPCR were obtained within 24 h. CONCLUSIONS: MPCR using IS6110, protein b, and MPB64 primers has a high sensitivity and specificity in rapid diagnosis of spinal tuberculosis. To the best of our knowledge, this has not been attempted before in spinal tuberculosis. This is particularly useful for paucibacillary infections like spinal tuberculosis. However, further studies using large sample sizes are needed to confirm the practical applicability of this technique.
Assuntos
Técnicas de Diagnóstico Molecular/métodos , Reação em Cadeia da Polimerase Multiplex/métodos , Tuberculose da Coluna Vertebral/diagnóstico , Feminino , Humanos , Masculino , Técnicas de Diagnóstico Molecular/normas , Reação em Cadeia da Polimerase Multiplex/normas , Mycobacterium tuberculosis/genética , Mycobacterium tuberculosis/isolamento & purificação , Projetos Piloto , Sensibilidade e Especificidade , Tuberculose da Coluna Vertebral/microbiologiaRESUMO
The Department of Neurosurgery started functioning at the Postgraduate Institute of Medical Education and Research, Chandigarh in 1962 with the joining of Dr. Gulati. The department provides neurosurgical services primarily to the people of Chandigarh, Punjab, Haryana, Himachal Pradesh, Jammu and Kashmir as well as the neighbouring areas of Rajasthan, Uttar Pradesh and Uttarakhand. The infrastructure and subspecialties have been developed over the last 5 decades by the dedicated and tireless efforts of the faculty and residents. We attempt to chronicle the contributions of those who have served the department in the past.
Assuntos
Academias e Institutos/história , Educação de Pós-Graduação em Medicina/história , Neurocirurgia/história , Procedimentos Neurocirúrgicos/história , Faculdades de Medicina/história , História do Século XX , História do Século XXI , Humanos , ÍndiaRESUMO
UNLABELLED: Object/Background: Vasospasm is a common cause of mortality and morbidity following rupture of intracranial aneurysm. Hemodynamic therapy instituted in these patients in the past has been replaced by direct manipulation of the spastic vessels by angioplasty and intra-arterial infusion of vasodilators. However, no case control studies exist proving its superiority. The purpose of our study was to compare the efficacy of intra-arterial nimodipine (IAN) to that of hemodynamic therapy in patients with vasospasm following aSAH. MATERIAL AND METHODS: Fifty-three patients who developed vasospasm following aSAH were included in the study. IAN was instilled in addition to hemodynamic therapy in 39 patients and 14 patients (who refused to give consent for IAN) were continued on hemodynamic therapy alone and served as controls. The response to IAN was studied on angiogram. The clinical response was assessed in both the groups at regular intervals. IAN was repeated if necessary. The outcome (GOS) at discharge and at 3 months after discharge was compared. RESULTS: Thirty-six (92.3%) out of 39 patients showed immediate angiographic reversal of vasospasm.28 of them showed clinical response, of which only 11 had lasting response. 11(28.2%) of 39 patients who received IAN had a good outcome at discharge and 23(58.9%) had a favourable outcome at 3 months follow up. In those who received hemodynamic therapy alone, 4 out of 14(28.6%) patients had a good outcome at discharge and 8 (57.1%) a favourable outcome at 3 months. CONCLUSIONS: Angiographic reversal of vasospasm is seen in majority of the patients following IAN. However, this does not necessarily translate into a long lasting clinical response. The final outcome in patients who received hemodynamic therapy is comparable to those who received additional IAN. IAN does not appear to provide a major added advantage over the conventional hemodynamic therapy.
Assuntos
Aneurisma Intracraniano/tratamento farmacológico , Nimodipina/administração & dosagem , Nimodipina/uso terapêutico , Hemorragia Subaracnóidea/tratamento farmacológico , Vasoespasmo Intracraniano/tratamento farmacológico , Adulto , Idoso , Feminino , Humanos , Infusões Intra-Arteriais/métodos , Aneurisma Intracraniano/complicações , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Hemorragia Subaracnóidea/complicações , Resultado do Tratamento , Vasodilatadores/uso terapêuticoRESUMO
Intracranial neurenteric cysts are rare. Diagnosis can only be established on histopathology with the demonstration of mucin-secreting cells in cyst wall. We report a midline, ventral, cystic lesion at the cervico-medullary junction, with the unusual radiological finding of a "fluid-fluid" level. Intraoperatively, the cyst contained fluid along with pus-like material with white flakes and specks of calcification, suggesting a dermoid cyst. However, histopathology confirmed the diagnosis of neurenteric cyst. The patient was managed with right lateral inferior suboccipital approach and near-total excision of the lesion.
Assuntos
Imageamento por Ressonância Magnética , Defeitos do Tubo Neural/patologia , Defeitos do Tubo Neural/cirurgia , Medula Espinal/cirurgia , Adulto , Biópsia , Diagnóstico Diferencial , Feminino , Humanos , Medula Espinal/patologia , Resultado do TratamentoRESUMO
Papillary tumor of the pineal region (PTPR) is a rare tumor of the pineal region. Not much is known about the pathogenesis, prognosis, and treatment protocol of this uncommon entity. We present three cases of PTPR with follow-up from 8 months to 98 months. All patients presented with headache and visual disturbance. One patient also had amenorrhea. Radiology revealed an heterogeneously enhancing mass arising from the pineal region with associated hydrocephalus. Histopathologically, all cases showed the papillary architecture, strong pan cytokeratin and cytokeratin 18 positivity, and faint positivity for synaptophysin and neuron-specific enolase. All cases received postoperative radiotherapy. One case showed tumor recurrence after 7 years. Other two cases did not show any recurrence till the last follow-up.
RESUMO
Bovine brucellosis is an economically important disease which seriously affects dairy farming by causing colossal losses. It can be controlled by practicing vaccination of animals with Brucella abortus S19 vaccine (S19 vaccine). In the present study, adult bovines were vaccinated on seven dairy farms with a reduced dose of S19 vaccine to control brucellosis. Serological screening of adult animals (N = 1,082) by Rose Bengal test (RBT) and ELISA prior to vaccination revealed the presence and absence of brucellosis on five and two farms, respectively. The positive animals (N = 171) were segregated and those which tested negative (N = 911) were vaccinated by conjunctival route with a booster after 4 months. The conjunctival vaccination induced weak antibody response in animals, which vanished within a period of 9 to 12 weeks. Abortion in 12 animals at various stages of pregnancy and post-vaccination was recorded, but none was attributed to S19 vaccine. However, virulent B. abortus was incriminated in six heifers, and the cause of abortion could not be established in six animals. The six aborted heifers perhaps acquired infection through in utero transmission or from the environment which remained undetected until abortion. These findings suggested that vaccination of adult animals with a reduced dose of S19 vaccine by conjunctival route did not produce adverse effects like abortion in pregnant animals and persistent vaccinal antibody titers, which are the major disadvantages of subcutaneous vaccination of adult animals.
Assuntos
Aborto Animal/prevenção & controle , Vacina contra Brucelose/imunologia , Brucella abortus/imunologia , Brucelose Bovina/prevenção & controle , Animais , Bovinos , Indústria de Laticínios , Ensaio de Imunoadsorção Enzimática , Feminino , Geografia , Índia , Transmissão Vertical de Doenças Infecciosas , Gravidez , Vacinação/veterináriaRESUMO
Persistent hydrocephalus is common in children after resection of posterior fossa tumours. However, occurrence of subdural hygroma is very rare. We report the case of a 14-month-old child who presented at a paediatric neurology clinic in Muscat, Oman in 2021 who developed a tense subdural hygroma with stable hydrocephalus, in the early postoperative period, following posterior fossa tumour resection. We describe the distinctive clinical, radiological and pathological features associated with the development of a tense subdural hygroma. We also discuss the management by cerebrospinal fluid diversion, which includes either a ventriculoperitoneal or subduroperitoneal shunt. This unique condition is distinguished from external hydrocephalus by features that are critical to the management strategy.
Assuntos
Neoplasias Infratentoriais , Derrame Subdural , Humanos , Neoplasias Infratentoriais/cirurgia , Derrame Subdural/etiologia , Lactente , Omã , Masculino , Hidrocefalia/etiologia , Hidrocefalia/cirurgia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/diagnóstico , Derivação Ventriculoperitoneal/efeitos adversos , Derivação Ventriculoperitoneal/métodos , FemininoRESUMO
PURPOSE: There is still no standard protocol for management of patients of tubercular meningitis (TBM) with hydrocephalus in poor neurological grade. In general, a trial of external ventricular drain (EVD) is an accepted method of treatment to decide whether a particular patient will benefit from shunt surgery. However, recent studies suggest that ventriculoperitoneal (VP) shunt may be undertaken without the trial of an EVD. Our study prospectively evaluates the role of direct VP shunt placement in poor grade patients of TBM with hydrocephalus. METHODS: Twenty-six consecutive pediatric patients of TBM with hydrocephalus in Palur grades III and IV underwent direct VP shunt placement, without prior placement of EVD. Outcome was assessed at the end of 3 months using Glasgow Outcome Score. RESULTS: The mean age of patients was 3.3 years (range, 4 months to 11 years). Twenty-one (80.8 %) patients were in grade III and five (19.2 %) were in grade IV. Good outcome and mortality in grade IV patients was 20 % (1/5) and 60 % (3/5) respectively; whereas in grade III patients, it was 71.4 % (15/21) and 9.5 % (2/21), respectively. Thirteen patients presented with focal neurological deficit at admission, which persisted in only three patients at 3 months follow up. VP shunt-related complications were observed in six (23.5 %) patients CONCLUSIONS: Despite poor grade at admission, 71.4 % patients in grade III and 20 % patients in grade IV had a good outcome at 3 months follow-up. Direct VP shunt placement is a safe and effective option even in poor grade patients of TBM with hydrocephalus, with a low complication rate.
Assuntos
Hidrocefalia/cirurgia , Tuberculose Meníngea/cirurgia , Derivação Ventriculoperitoneal/métodos , Criança , Pré-Escolar , Feminino , Seguimentos , Humanos , Hidrocefalia/etiologia , Lactente , Masculino , Estudos Prospectivos , Índice de Gravidade de Doença , Resultado do Tratamento , Tuberculose Meníngea/complicações , Tuberculose Meníngea/mortalidade , Derivação Ventriculoperitoneal/efeitos adversos , Derivação Ventriculoperitoneal/instrumentaçãoRESUMO
BACKGROUND: Elective temporary clipping (ETC) is increasingly used in surgery for aneurysms. This study was to assess whether the impact of ETC on intraoperative aneurysmal rupture (IAR) translates into neurological outcome. METHODS: Patients who underwent surgery for ruptured anterior circulation aneurysms were prospectively studied for various factors related to ETC, IAR and neurological outcome at 3 months. Univariate and multivariate analyses were performed using SPSS20. RESULTS: Of the total 273 ruptured aneurysm surgeries studied, IAR was observed in only six out of 132 aneurysms (4.5 %) who had ETC, compared with 78 out of 141 (55.3 %) without ETC (p < 0.001). Aneurysms complicated by IAR had significantly longer clipping time (8.3 min) compared with those without IAR (1.9 min) (p < 0.001). IAR had significant association with unfavorable outcome (38 % vs. 24 %) (p = 0.02). Patients with ETC had significantly shorter clipping time (2.9 min) compared with those without ETC (4.8 min) (p = 0.02). Unfavorable outcome was noted in 30 out of 132 with ETC (23 %), compared with 48 out of 141 without ETC (34 %) (p = 0.04). This beneficial effect was nonsignificantly greater in younger and good clinical grade patients. While episodes of ETC within clipping time of 20 min did not show significant difference in outcome, repeated rescue clipping (45 % unfavorable outcome, p = 0.048) and total clipping time of at least 20 min (75 % unfavorable outcome, p = 0.008) had significant impact on outcome. In multivariate analysis, the use of ETC (p = 0.027) and total temporary clipping less than 20 min (p = 0.049) were noted to result in significantly better outcome, independent of other factors. CONCLUSIONS: The use of ETC decreased the occurrence of IAR and the total clipping time, thereby leading to significantly better outcome, independent of other factors. While repeated elective clipping within total clipping time of 20 min did not influence outcome, repeated rescue clipping and total clipping time of at least 20 min had significant impact on outcome.
Assuntos
Aneurisma Roto/epidemiologia , Aneurisma Roto/prevenção & controle , Procedimentos Cirúrgicos Eletivos , Aneurisma Intracraniano/cirurgia , Complicações Intraoperatórias , Adolescente , Adulto , Idoso , Aneurisma Roto/diagnóstico , Feminino , Seguimentos , Escala de Resultado de Glasgow , Humanos , Incidência , Aneurisma Intracraniano/complicações , Aneurisma Intracraniano/diagnóstico , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Fatores de Risco , Resultado do Tratamento , Adulto JovemRESUMO
Herd and individual animal prevalence along with associated risk factors of bovine brucellosis was assessed on dairy farms located in 22 districts in Haryana and Punjab of India. Examination of 4,580 female animals of 119 dairy farms by Rose Bengal test and enzyme-linked immunosorbent assay revealed that an overall herd prevalence was 65.54% (78/119) and individual animal prevalence was 26.50 % (1,214/4,580). Herd prevalence in Haryana was 62.79% which was not significantly different (P = 0.4208) from Punjab (72.72%). Individual animal prevalence was 34.15% in Punjab which was significantly higher (P < 0.0001) than Haryana (22.34%). Prevalence of brucellosis on dairy farms was detected in 20 of the 22 districts, of which 12 districts were in Haryana and 8 in Punjab. Risk factors such as species of animals, age of animals, herd size, awareness of dairymen for brucellosis, entry of a purchased animals on the farm, abortion on farm, use of calving pens, type of breeding, and type of farming were analyzed. The study indicated that the odds ratio (OR) was significant with risk factors of species (OR = 1.63; 95 %CI = 1.40-1.90; P < 0.0001), age (OR = 0.22; 95%CI = 0.17-0.29; P < 0.0001), awareness of brucellosis among dairymen (OR = 21.65; 95%CI = 2.63-178.04; P = 0.0042), entry of purchased animal on the farm (OR = 9.16; 95%CI = 2.38-35.18; P = 0.0012), abortion in animals (OR = 5.57; 95%CI = 1.92-16.10; P = 0.0015) and on cow farm (OR = 3.43; 95 %CI = 1.33-8.82; P = 0.0105). While the OR was insignificant (P > 0.05) with risk factors of herd size, use of calving pen on farms, type of breeding and on buffalo and mixed type of farms.