Ankur Kapoor

Validation of a New Clinico-Radiological Grading for Compound Head Injury: Implications on the Prognosis and the Need for Surgical Intervention

BACKGROUND Lack of risk stratification among patients with varying severities of compound head injury has resulted in too-inconsistent and conflicting results to support any management strategy over another. The purpose of this study was to validate a new clinico-radiological grading scheme with implications on outcome and the need for surgical debridement. METHODS Patients who sustained an external compound head injury with no serious systemic injury and no pre-established infection and who continued the entire treatment were studied prospectively for their proposed grade of compound injury in relation to infective complications, unfavorable Glasgow Outcome Scale (GOS), delayed seizures, mortality, and hospital stay for 3 months. Appropriate univariate and multivariate analyses were performed. RESULTS Among a total of 344 patients, 182 (53%) had no dural violation or midline shift (Grade 1), 56 (16%) had cerebrospinal fluid leak or pneumocephalus (Grade 2), 34 (10%) had exposed brain (Grade 3), 47 (14%) had midline shift (Grade 4), and 25 (7%) had both exposed brain and midline shift (Grade 5). Each successive grade of compound injury had significant incremental impact on all the outcome measures studied. Infective complications in Grades 1 to 5 were noted among 7%, 9%, 27%, 28%, and 36% of patients, respectively (P < 0.001). There was a significant difference in unfavorable GOS (23% vs. 56%, odds ratio [OR] 4.3, P < 0.001) and mortality (17% vs. 42%, OR 3.5, P < 0.001) between Grades 1-2 and Grades 3-5. Delayed seizures were noted in 4%, 4%, 9%, 13%, and 16% of patients in Grades 1-5 (P = 0.04). The median hospital stay was 1, 3, 6, 6, and 8 days, respectively (P < 0.001). All patients in Grades 4-5 (72) underwent surgery. Only 32 of 182 (18%) patients in Grade 1, 9 of 56 (16%) patients in Grade 2, and 23 of 34 (68%) patients in Grade 3 underwent surgical debridement, whereas the rest were managed conservatively. Patients who were managed conservatively had significantly lower infective complications (3% vs. 25%, OR 9.67, P < 0.001) in Grade 1, and (2% vs. 44%, OR 36.8, P = 0.002) in Grade 2, compared with those who underwent surgical debridement. In multivariate analysis, the proposed grade had significant independent association with infection (P < 0.001), unfavorable GOS (P = 0.01), delayed seizures (P = 0.001), and hospital stay (P < 0.001), and each successive grade had significant incremental impact on both infective complications and unfavourable GOS, independent of GCS and other prognostic factors. CONCLUSION The new grading scheme appears to be of practical clinical significance. It shows significant statistical associations with the rates of infection, unfavorable neurologic outcome, delayed seizures, mortality, and duration of hospital stay. The incremental impact of each successive grade on infective complications and unfavorable GOS was independent of GCS and other prognostic factors. Conservative management had significantly lower infection compared to surgical debridement, at least in patients with Grades 1 and 2.

Study of trends in anthropometric nutritional indices and the impact of adiposity among patients of subarachnoid hemorrhage

BACKGROUND Nutritional status and adiposity have not been studied to a significant extent in subarachnoid hemorrhage (SAH). The aim of this study was to determine the trends in anthropometric indices and assess their impact on patients with SAH. METHODS We prospectively studied in 56 patients with SAH, the triceps skinfold thickness (TSF), mid-arm circumference (MAC), mid-arm muscle circumference (MAMC), and other factors, and their relationship to clinical vasospasm and mortality. RESULTS The median MAC decreased significantly from 29.3 cm (interquartile range [IQR] 28-31 cm) at admission to 27 cm (IQR 26-29 cm) at 1-week (P < 0.001). The median TSF decreased significantly from 34 mm (IQR 30-40 mm) at admission to 30 mm (IQR 25-35 mm) at 1-week (P < 0.001). MAMC values did not show a significant change over a week. The patients who developed clinical vasospasm had significantly higher median admission TSF of 40 mm (IQR 35-45 mm), compared to the median admission TSF of 35 mm (IQR 30-40 mm) among those who did not develop vasospasm (P = 0.03). MAMC values did not differ significantly in relation to vasospasm. Patients who expired by 3 months had significantly greater fall in median MAMC values at 1-week (7.7% [IQR 5.2-11.5%]), compared to the fall in median MAMC values at 1-week among those who were alive at 3 months (2.6% [IQR 2.1-6.6%]) [P = 0.03]. However, the fall in TSF values did not differ significantly in relation to mortality. In multivariate analysis, only the admission TSF, Hunt and Hess and Fisher grades had a significant association with vasospasm. This association was independent of other prognostic factors and of each other. CONCLUSION Excessive adiposity of patients, measured as an increased TSF value, is significantly associated with clinical vasospasm independent of other prognostic factors, while fall in MAMC, indicating somatic protein catabolism, has some impact on mortality.

Spontaneous hemorrhages in pediatric supratentorial pilocytic astrocytomas. Malignant presentation of a benign entity.

BackgroundHemorrhage as a presenting feature in pilocytic astrocytoma is an extremely rare phenomenon. When seen in children, most of such tumors exist in the cerebellum. Rarely, a supratentorial pilocytic astrocytoma can present with bleeding.ResultsWe present similar two cases and discuss the pathophysiology of such hemorrhage and histopathological changes in thinned hyalinised vessels of this tumor.ConclusionThe presence of calcifications in the peri-hemorrhagic areas and the presence of mass effect disproportionate to the size of the bleeding are harbingers of the presence of a benign neoplasm that may have bled.

An orphan disease: IgG4-related spinal pachymeningitis: report of 2 cases.

IgG4-related disease is relatively new disease entity and a rare one, and our knowledge of this entity continues to evolve. It was first described in the pancreas and since then has been described in virtually every organ. Spinal involvement resulting in pachymeningitis is rare, and there are only 8 reported cases of the same to date, with the cervicothoracic spine being the most commonly affected region. The authors describe 2 cases in which the patients presented with spinal compression resulting in myeloradiculopathy (Case 1) and radiculopathy (Case 2). Imaging of spine in both cases revealed an ill-defined contrast-enhancing lesion at the lumbar level. Preoperatively, a diagnosis of spinal tumor was made, but intraoperatively no spinal tumor was found. The diagnosis was established histopathologically. The disease has no particular defining features clinically or radiologically and can mimic common spinal tumors. It is important to accurately diagnose this rare entity because of its multisystem involvement and progressive course. Strict treatment guidelines have yet to be formulated. Although histologically this disease can mimic other inflammatory conditions, the presence of storiform fibrosis and an increased number of IgG4-positive plasma cells can help in clarifying the diagnosis.

Hemorrhage in astroblastoma: An unusual manifestation of an extremely rare entity.

Astroblastoma is a rare tumor of glial origin with characteristics of both astrocytoma and ependymoma. It is usually seen in children and young adults, and is peripherally located, well circumscribed, of solid-cystic composition and with heterogeneous contrast enhancement. Histopathology reveals perivascular pseudorosette formation and thick hyalinised vessels. Hemorrhage in astroblastoma is unusual and rarely described in literature. We report two patients with astroblastoma who presented with hemorrhage and discuss the natural history, radiological findings, pathophysiology of hemorrhage and histopathological characteristics. We emphasize the importance of early suspicion in peripherally located lesions with bleeding.

Symptomatic contralateral subdural hygromas after decompressive craniectomy: plausible causes and management protocols

OBJECT Contralateral subdural hygromas are occasionally observed after decompressive craniectomies (DCs). Some of these hygromas are symptomatic, and the etiology and management of these symptomatic contralateral subdural collections (CLDCs) present surgical challenges. The authors share their experience with managing symptomatic CLSDCs after a DC. METHODS During a 10-month period, 306 patients underwent a DC. Of these patients, 266 had a head injury, 25 a middle cerebral artery infarction (that is, a thrombotic stroke), and 15 an infarction due to a vasospasm (resulting from an aneurysmal subarachnoid hemorrhage [SAH]). Seventeen patients (15 with a head injury and 2 with an SAH) developed a CLSDC, and 7 of these patients showed overt symptoms of the fluid collection. These patients were treated with a trial intervention consisting of bur hole drainage followed by cranioplasty. If required, a ventriculo- or thecoperitoneal shunt was inserted at a later time. RESULTS Seven patients developed a symptomatic CLSDC after a DC, 6 of whom had a head injury and 1 had an SAH. The average length of time between the DC and CLSDC formation was 24 days. Fluid drainage via a bur hole was attempted in the first 5 patients. However, symptoms in these patients improved only temporarily. All 7 patients (including the 5 in whom the bur hole drainage had failed and 2 directly after the DC) underwent a cranioplasty, and the CLSDC resolved in all of these patients. The average time it took for the CLSDC to resolve after the cranioplasty was 34 days. Three patients developed hydrocephalus after the cranioplasty, requiring a diversion procedure, and 1 patient contracted meningitis and died. CONCLUSIONS Arachnoid tears and blockage of arachnoid villi appear to be the underlying causes of a CLSDC. The absence of sufficient fluid pressure required for CSF absorption after a DC further aggravates such fluid collections. Underlying hydrocephalus may appear as subdural collections in some patients after the DC. Bur hole drainage appears to be only a temporary measure and leads to recurrence of a CLSDC. Therefore, cranioplasty is the definitive treatment for such collections and, if performed early, may even avert CLSDC formation. A temporary ventriculostomy or an external lumbar drainage may be added to aid the cranioplasty and may be removed postoperatively. Ventriculoperitoneal or thecoperitoneal shunting may be required for patients in whom a hydrocephalus manifests after cranioplasty and underlies the CLSDC.

Serum albumin level in spontaneous subarachnoid haemorrhage: More than a mere nutritional marker!

Abstract Background: The role of nutritional markers on outcome following subarachnoid hemorrhage (SAH) has been scarcely described. Methods: This is a prospective study of 273 patients with SAH, in which haemoglobin, serum protein and albumin were measured within 24 hours and again at one week following ictus, and analysed with respect to other variables. New neurologic deficits (NND), infarct, mortality and Glasgow outcome scale (GOS) at 3 months were assessed. Results: The values of haemoglobin, total protein and albumin showed significant (p < .001) decline over the first week of SAH. Patients who developed NND had significantly lower serum albumin levels at admission compared to others (median 3.6 vs 3.9 g/dL, p < .001). Patients having lower albumin (≤3.5 gm/dL) levels at admission had significantly higher rates of NND (52% vs 20%), infarct (35% vs 23%), mortality (28% vs 16%) and unfavourable GOS (38% vs 25%). Hunt & Hess (H&H) grade and Fisher grade also affected all the outcome parameters significantly. Percentage decrease in albumin levels at one week following ictus significantly affected mortality and unfavourable GOS. On multivariate analyses, Fisher grade and lower admission albumin levels had significant impact on NND, while percentage decrease in albumin levels had significant impact on mortality and unfavourable GOS, independent of other nutritional markers and known prognostic variables. Conclusions: Serum albumin levels following SAH can be useful to predict development of NND, while its further weekly decrease correlates independently with unfavourable outcome at 3 months. Albumin assessment being readily available may serve as more than a mere nutritional parameter in SAH.

Sphenoid bone: a rare site for giant cell tumor - case report with literature review.

While giant cell tumor is commonly a tumor of long bones, involvement of sphenoid bone is very rare. Clinically and radiologically, it mimics other neoplasms of this site. Endochondral ossification of this bone during development explains its curious preferential involvement in comparison to the rest of the skull bones. We describe an example of such a tumor arising in the sphenoid bone in a young woman and discuss the differential diagnosis. Recognizing its characteristic features is important for correct interpretation.
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The triad of holocord syringomyelia, Chiari malformation and tethered cord: amelioration with simple detethering--a case for revisiting traction hypothesis?

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Ruptured Intracranial Dermoid: Is Surgery Indispensible: 11-Year Follow-Up of a Rare Entity

BACKGROUND Dermoid cysts are rare intracranial lesions that can occasionally rupture into intraventricular and subarachnoid spaces and can present with a myriad of symptoms. The surgical intervention in such cases is demanding, because the disseminated contents are spread widely in intraventricular and subarachnoid space. CASE DESCRIPTION A 22-year-old female patient who presented with history of seizures was diagnosed as having a left parasellar ruptured dermoid. Because there were no features of increased intracranial pressure, conservative management was considered with antiepileptic administration. At 11 years of follow-up, the patient continues to do well on 2 antiepileptics with repeat imaging showing no change in size of lesion. CONCLUSIONS Surgical intervention may not be essential in all patients with ruptured intracranial dermoids. In a few selected patients who do not manifest increased intracranial pressure and show no change in the size of the lesion on sequential radiologic follow-up, conservative management may be attempted, especially when the ruptured intracranial dermoid is located at eloquent areas and with wide dissemination of contents.