Anil Dhar

Elevated skull fractures in pediatric age group: Report of two cases

Elevated fractures of the skull, which are rarely reported in the literature, are always compound, have maximal neurological deficits at presentation and have been reported only in adults. We report two cases of elevated skull fractures in the pediatric age group, one of which was a simple elevated fracture and presented with delayed neurological deterioration. The etiologies were a fall in first case and an animal attack (bear maul) in the second case as reported for the first time. One of the cases presented with delayed onset of left focal hemispheric signs. The first case underwent debridement, duraplasty and reduction of fracture whereas in the second case the bone flap was not replaced immediately because of gross contamination. Both patients had an excellent outcome. Elevated skull fractures are not uncommon in the pediatric age group. Compound elevated skull fractures should be managed early as open depressed fractures. Reduction of a simple elevated fracture presenting with neurological deficits not explained by any other lesion can result in a good outcome.

Childhood Tumors of the Brain: Demographic Pattern over a Ten-Year Period in the Kashmir Valley

Brain tumors in children represent the second most frequent tumors in this age group after hematologic malignancies. We highlight the demographic pattern after retrospective analysis of brain tumors in children from geographically and ethnically distinct Kashmir Valley managed in our center between 2000 and 2009. We had a total of 248 pediatric patients with brain tumors. The parameters analyzed were age, gender, location of tumors and histopathological subtypes as well as WHO grade of tumor. We also did a comparison between the frequencies of common varieties of tumor in the first and second 5-year periods. We found that 111 tumors (44.75%) were supratentorial, and 137 (55.25%) were infratentorial. The male-to-female ratio was 1.4:1. The proportions of low-grade and high-grade tumors were 60 and 40%, respectively. The most common tumor in our series was astrocytoma. The most common tumors in the supratentorial and infratentorial compartments were craniopharyngioma and medulloblastoma, respectively. Our experience reflects a different demographic profile of pediatric brain tumors as compared with other regions of the world.

Stray bullet: An accidental killer during riot control

Background: The use of force to control public uprisings, riots, unruly mobs is an important tool in any administrative setup. Law enforcement agencies often resort to aerial firing, which can be responsible for unintended injuries due to stray bullets.This study was designed to study the pattern of stray bullet injuries and to generate awareness about the hazards related to the use of live ammunition during riot control. Methods: This study was conducted in our unit of the neurosurgery department over a period of 18 months, from June 2008 to December 2010. We enrolled all patients who had head or spine injuries caused by stray bullets from firing during riot control far away from the site of injury. Results: We had two patients with head injury and two with spinal injury sustained because of stray bullets. One of the patients with head injury was operated and the other one was managed conservatively; the latter died on the third day of injury, while the former is surviving with some residual neurological deficit. Amongst the patients with spinal injury, neurological deficits persist till date. None of the patients were aware that they had sustained a bullet injury, and it was only after inquiry that we came to know that the police had resorted to aerial firing for controlling public agitation in nearby areas. Conclusion: Aerial firing of live cartridges is generally considered an ‘innocuous’ method; however, in view of the potential for injury to innocent bystanders, we recommend that the use of live cartridges during aerial firing be banned.

Conservative Management of Bomb Shrapnel Injuries to the Brain

AimThis was a prospective study that aimed to analyze the efficacy of conservative management in patients with shrapnel injuries (SI) due to bomb blasts. MethodsPatients with SI to the brain due to bomb blasts during the study period were enrolled in the study. After initial resuscitation, the patients were divided into 2 groups. Group 1 was the one in which patients were managed by supportive care with or without simple wound closure. In group 2, all patients were managed operatively (OM) provided they met the inclusion criteria. ResultsIn the study group, 61 patients with SI due to bomb blasts were enrolled. Out of 61 patients, 46 (75.4%) had favorable outcome and 15 (24.6%) had unfavorable outcome. Of the 45 patients in conservatively managed group, 37 (82.2%) had a favorable outcome whereas 8 (17.8%) had an unfavorable outcome. In the OM group, 9 (56.3%) had a favorable and 7 (43.8%) had an unfavorable outcome. This was mostly because of poor neurologic status of the patients in the OM group. However, the 2 groups did not have a significant difference in postoperative incidence of infections and seizures. ConclusionsThis study is not intended to minimize the importance of surgical management of penetrating missile injuries to the head. Such treatment is most often necessary in cases with definite indications. Conservative management (supportive care) alone or along with simple wound closure is equally effective and has now become an important choice for neurosurgeons facing a large number of casualties, particularly in developing countries.

Vertex epidural hematoma with bilateral abducent nerve palsy: case report and literature review.

Epidural hematomas which are located at the vertex are rarely seen and form a small percentage of total epidural hematomas. Tearing in the superior sagittal sinus is the usual cause of an epidural hematoma located in the vertex. The clinical features of this entity are non-specific; hence, localization of the lesion is difficult. We report an adult who was hit by a motorcycle and was initially discharged from the hospital as a case of concussional head injury. He returned back with raised intracranial pressure symptoms, so a CT scan was done but was misinterpreted, and he reported one week later with bilateral abducent nerve palsy. Magnetic resonance imaging confirmed vertex EDH for which he was operated.These hematomas are seen rarely and can be interpreted as an artifact. Its recognition is important because it has an excellent prognosis. We concluded that all head injury patients should get high axial cuts on the CT scan, and any degree of suspicion should prompt a neurosurgeon to investigate further with coronal CT scan or MRI.

Brain abscess complicating hemorrhagic contusion in a case of closed head injury: Case report

Brain contusions commonly are identified in patients with traumatic brain injury (TBI) and represent regions of primary neuronal and vascular injury. These edematous lesions contain punctate parenchymal hemorrhages, which are termed micro-hemorrhages. These hemorrhages rarely get infected by hematogenous spread of microorganisms causing a brain abscess. Delayed brain abscess formation in the contusion is a very rare entity. We report a one year old patient who had traumatic right parietal hemorrhagic contusion with no external wound. She was managed conservatively. Two weeks after injury he deteriorated in neurological status and was found to have developed brain abscess. Patient underwent immediate craniotomy with drainage of abscess and excision of abscess wall; she was discharged home after one week. Infective complication can occur rarely even after closed head injury and should be kept as a differential diagnosis in a patient with delayed deterioration.

Isolated third nerve palsy due to mesencephalic hematoma

Isolated cranial nerve palsy is an uncommon sequel in head injury. A 9-year-old child was admitted in comatose condition after falling from a house with right pupil dilatation and same eyeball deviated laterally. Clinical impression was that of a right sided traumatic hematoma and resulting uncal herniation leading to third nerve palsy. However, CT scan revealed a small hemorrhage in anterior tegmentum on right side. The majority of third nerve palsies following trauma have been reported due to lateral herniation syndrome but isolated third nerve palsy due to tegmental herniation is rare entity.

Newer Technique of Using Indigenous Tubular Retractor (Tailored 5-mL Syringe) for Microscopic Excision of Third Ventricular Colloid Cysts

Colloid cysts are benign space-occupying lesions that account for 0.5% to 1.0% of brain tumors and arise from the velum interpositum or the choroid plexus of the third ventricle. We are describing a modified surgical technique that combines the positive attributes of being minimalistic while retaining the effectiveness of microsurgery. In all 20 consecutive symptomatic patients with a preoperative magnetic resonance imaging diagnosis of colloid cyst who came to the senior author between 2008 and 2011 were included in the study. The patient was kept supine with the head positioned neutrally in the saggital plane and neck flexed at 20 degrees. The tube of a 5-mL plastic syringe having an external diameter of 13 mm and an internal diameter of 12.6 mm was cut towards the nozzle end to an appropriate length depending upon the cortical thickness measured on the preoperative magnetic resonance imaging. Microsurgical excision using tubular retractor was performed in all the cases. Average operative time was around 90 minutes with maximum of 120 minutes. None of the patients had seizures preoperatively or postoperatively and in all cases antiepileptic medication could be stopped after 3 to 6 months of surgery. Two patients had short-term memory impairment which returned to near-normal by 1 year after surgery.

Can Paper Clips Replace Raney Clips for Scalp Hemostasis?: Results of a Randomized Trial

BackgroundScalp hemostasis during neurosurgical practice is a must. There are various methods to attain it. We endeavored to evaluate the efficacy of locally available metal paper clips for this purpose. ObjectiveTo evaluate the efficacy and safety of paper clips and their comparison with Raney clips for scalp hemostasis during craniotomy. Patients and MethodsSeventy-six patients were randomized into 2 groups: group A—patients in whom Raney clips were applied for scalp hemostasis and group B—patients in whom metal paper clips were used. Follow-up at 1 month was available in 68 patients. Patients with previous scalp surgeries or craniotomies were excluded from the trial. The wounds were assessed by an investigator, who was blind to the type of the scalp clips used. ResultsThe results revealed that there was no statistically significant difference in wound healing characteristics of these 2 groups at 1-month period after surgery. ConclusionsThe use of metal paper clips for scalp hemostasis during craniotomy is safe, cheaper than and as effective as Raney clips.

Hypodensity of extradural hematomas in children: an ominous sign.

OBJECT The aim of this study was to analyze the correlation of hypodensity in extradural hematomas on CT with the clinical profile in pediatric patients. This is the only study available in this age group. METHODS This was a prospective study conducted over a period of 3 years in which all children 18 years old or younger with a diagnosis of cranial extradural hematoma were included. The patients were allocated to 2 groups: those with mixed-density clots (17 cases) and those with classically hyperdense clots (52 cases). A comparative analysis between the 2 groups was conducted. RESULTS Patients with mixed-density clots presented earlier to the hospital, had poor Glasgow Coma Scale scores at admission, exhibited large clot volumes, had a high incidence of active bleeding at surgery, and had increased morbidity and mortality as compared with the patients with hyperdense extradural hematomas. CONCLUSIONS Early recognition and rapid evacuation of the mixed-density clot with restoration of hemostasis may result in a decline in morbidity and death in children with this entity.