Ajay Hegde

Shunt malfunction in patients with hydrocephalus: complications revisited

The ventriculoperitoneal shunt has been the mainstay for definitive treatment of hydrocephalus since time immemorial. As such, several case reports describing the complications of this procedure have been documented in the literature over the past few decades. The spectrum ranges from ventricular catheter dislodgement to abdominal catheter end perforating the stomach and causing intussusception; several case illustrations have depicted the possible aftermath of this blind procedure. After the advent of neuronavigation and planning procedures on CT scans, the complication rates have significantly reduced.nnShunt malfunction, secondary to migration of the abdominal end, remains as one of the most common complications following ventriculoperitoneal shunting.1 Large bowel perforation is a rare complication with an incidence of 0.1–0.7%.2 In rare instances, there have been cases of herniation of the peritoneum along with the distal end of the catheter through a lax posterior rectus sheath.3 The unprecedented cases we describe, the first of a child and the other of an elderly woman, mandate a separate mention in the literature. We present our institutional experience, treatment dilemma, surgical management and outcomes in both the patients.nnCase 1: A 1½-year-old boy presented with intermittent appearance of the distal end of a ventriculoperitoneal shunt tube …

Neurogenic pulmonary oedema complicating traumatic posterior fossa extradural haematoma: Case report and review.

Abstract Introduction: Pulmonary oedema is accumulation of fluid in the lung air spaces and interstitia. Neurogenic pulmonary oedema (NPE) is a potentially life-threatening condition which has been noted in head injury, subarachnoid haemorrhage (SAH), intracerebral haemorrhage (ICH) and others. Timely management is crucial to achieve good outcome; however, no specific guidelines have been defined. Methods: A 33-year female involved in a motor vehicular accident had a GCS of 14/15 and CT scan showed a moderate-sized unilateral posterior fossa extradural haematoma (PFEDH). She had sudden deterioration in her haemodynamic status with drop in sensorium 2 hours after admission. There was a copious amount of frothy secretions noted on intubation and she was diagnosed as having NPE. Results: Sub-occiptial craneictomy (SOC) with haematoma evacuation was performed and was managed with PEEP mechanical ventilation post-operatively. Excellent outcome was obtained and was discharged with a GOS of 5. Conclusions: NPE is a poorly understood and uncommon complication of acute CNS injury and should be considered in any patient with acute respiratory distress in the setting of CNS injury. Reduction in ICP and supportive mechanical ventilation form the mainstay of management. Diagnosis of NPE remains challenging and more reliable diagnostic criteria need to be defined to identify such cases with greater frequency.

Spontaneous intracerebral hemorrhage in hemophiliacs—A treatment dilemma

Highlights • Spontaneous intracerebral hemorrhage poses a risk in all patients and a treatment dilemma in patients with bleeding and clotting disorders. The haemophiliac patient is a rare and challenging vignette to the average neurosurgeon.• Routine treatment would surmise with a craniotomy and evacuation of the haematoma, however this form of intervention is associated withsignificant morbidity and rebleed rates.• Our management involved close monitoring of the patient while we converted the acute hematoma into a chronic subdural hematoma and successfully managed it with burr hole evacuation under cover of antihemophilic factor.• Dosage and monitoring of AHF is described in detail.

Influence of Admission Blood Glucose in Predicting Outcome in Patients With Spontaneous Intracerebral Hematoma

Background and Aims: Hyperglycemia or elevated blood glucose levels have been associated with poor outcomes in patients with ischemic stroke yet control of hyperglycemia has not resulted in good outcomes. High admission blood glucose (ABG) values have been mitigated by other poor prognosticators like large hematoma volume, intraventricular extension (IVE) of hematoma and poor GCS. The aim of this study was to evaluate the effects of blood glucose levels at admission, on mortality and functional outcomes at discharge and 3 months follow up. Methods: This was a retrospective observational study conducted at a tertiary care. Patients with spontaneous SICH were enrolled from a prospective SICH register maintained at our hospital. Blood glucose values were recorded on admission. Patients with traumatic hematomas, vascular malformations, aneurysms, and coagulation abnormalities were excluded from our study. Results: A total of 510 patients were included in the study. We dichotomised our cohort into two groups, group A with ABG>160 mg/dl and group B with ABG<160 mg/dl. Mean blood glucose levels in these two groups were 220.73 mg/dl and 124.37 mg/dl respectively, with group A having twice the mortality. mRS at discharge and 3 months was better in Group B (p ≤ 0.001) as compared to Group A. Age, GCS, volume of hematoma, ABG, IVE and Hydrocephalus were significant predictors of mortality and poor outcome on univariate analysis with a p < 0.05. The relationship between ABG and mortality (P = 0.249, 95% CI 0.948–1.006) and outcome (P = 0.538, 95% CI 0.997–1.005) failed to reach statistical significance on multivariate logistic regression. Age, Volume of hematoma and GCS were stronger predictors of mortality and morbidity. Conclusion: Admission blood glucose levels was not an independent predictor of mortality in our study when adjusted with age, GCS, and hematoma volume. The effect of high ABG on SICH outcome is probably multifactorial and warrants further research.

Spinal Intramedullary Abscess Secondary to Dermal Sinus in Children

Introduction Congenital dermal sinuses (CDS) are uncommon lesions. They are most often noted in lumbosacral region and may lead to meningitis or spinal abscess. Intramedullary spinal cord abscess (IMSCA) due to CDS is rare and often co‐exists with an inclusion tumor such as dermoid/epidermoid cyst. Materials and Methods Literature review was done to analyze all cases of pediatric IMSCA secondary to CDS by searching online databases starting from the oldest case reported. Results Only 50 cases have been reported and were analyzed. Mean age was 22.6 months (range 1 month‐15 years). Fever, acute flaccid lower limb weakness, and urinary disturbances were the most common presenting features. Dermal sinus was commonest in lumbosacral region. Inclusion cysts were observed in 50% of cases. Staphylococcus aureus was the most the common organism. Mean follow‐up duration was 18.2 months (range 1 week‐156 months). Majority of the cases underwent multilevel laminectomy with myelotomy and drainage of abscess. Outcome was good‐to‐excellent in around 60% cases with four deaths. Presence of fever and limb weakness was significantly associated with poor outcomes. Conclusion Intramedullary abscess secondary to CDS is very rare. Complete sinus tract excision, myelotomy and drainage of abscess, and decompression of co‐existent inclusion cysts with prolonged antibiotic therapy remain the standard treatment. Approximately 60% cases achieve good outcomes. Fever and limb weakness portend poorer outcomes than those without.

Chronic Subdural Hematoma Associated with Congenital Arachnoid Cysts: Management Dilemmas

Chronic subdural hematoma (CSDH) is one of the commonest diseases encountered by a neurosurgeon in daily practice. It is however rarely seen in young patients. Congenital arachnoid cysts have been implicated in both traumatic and spontaneous CSDH in young individuals. Optimum treatment strategies to address the CSDH and arachnoid cyst are not very well described. We report a young gentleman who was treated for a CSDH with arachnoid cysts, two months after a mild head injury. The patient was operated with a simple burr hole drainage of hematoma with a drain. He was discharged with no further need to address the arachnoid cyst. CSDH associated with arachnoid cysts can be treated with simple burr hole drainage. Craniotomy, fenestration and cerebrospinal fluid (CSF) diversion should be reserved only as secondary procedures.

Misguided urinary catheter: an uncommon complication of a common solution

A 61-year-old man was wheeled in to our emergency triage bleeding profusely from his mouth and nose in an unconscious state. His Glasgow Coma Scale was 7 and was intubated for airway safety. A failed anterior nasal packing was followed by insertion of a Foley urinary catheter through the right nostril to secure posterior nasal packing and haemostasis. CT of the brain following nasalxa0packing showed diffuse traumatic subarachnoid haemorrhage and basifrontal contusions with multiple fractures of the anterior cranial fossa, cribriform plate including the frontal sinus. Multiple specs of air in the frontal lobe was initially …

Role of dynamic MRI in occult cervical canal stenosis

A 61-year-old elderly man presented to us with complaints of neck pain radiating to bilateral upper limbs with associated tingling and numbness of all four limbs since 8u2009months. He also had difficulty in walking and performing fine motor activities with his hands. On examination, he had spasticity of all four limbs, with exaggerated reflexes and power of 4/5 in his limbs. On evaluation with a static MRI of the cervical spine, a T2 cord signal hyperintensity was found at the C3–4 junction with no compression noted in sagittal and axial MRI sections. A dynamic X-ray of the cervical spine showed grade 1 …

Primary Orbital Follicular Lymphoma: A Case Report and Review

Orbital Lymphomas (OL) constitute a heterogeneous group of lymphoproliferative disorders of the orbit. They are predominantly of the Mucosa-Associated Lymphoid Tissue (MALT) subtype. Radiotherapy is the mainstay of treatment in localized orbital tumours, while chemotherapy is reserved for systemic disease. Authors report a case of a primary orbital lymphoma of follicular subtype (stage 1E) in a 54-year-old female managed by surgery and adjuvant radiotherapy.