Arif Hussain Sarmast

Role of external ventricular drainage in the management of intraventricular hemorrhage; its complications and management

Background: External ventricular drainage (EVD) is the procedure of choice for the treatment of acute hydrocephalus and increased intracranial pressure in patients of subarachnoid hemorrhage (SAH) and intracerebral hemorrhage with hydrocephalus and its sequelae. We evaluated the use of EVD in patients of SAHs (spontaneous/posttraumatic with/without hydrocephalus), hypertensive intracerebral bleeds with interventricular extensions, along with evaluation of the frequency of occurrence of complications of the procedure, infectious and noninfectious, and their management. Methods: During the period of 2½ years, between September 2012 and February 2015, 130 patients were subjected to external drainage procedure and were prospectively enrolled in this study. Information was collected on each patient regarding age, sex, diagnosis, underlying illness, secondary complications, other coexisting infections, use of systemic steroids, antibiotic treatment (systemic and intraventricular), and whether any other neurosurgical procedures were performed within 2 weeks of EVD insertion or any time the duration of ventriculostomy. Results: The study population of 130 patients underwent a total of 193 ventriculostomies. Thirty-six patients had ventriculostomy infection (27.6%). Evaluation of the use of EVD was done by comparing preoperative and postoperative grading scores. Forty-nine patients survived and improved their score from Grade 3–5 to Grade 2–4. Twenty-nine patients were moderately disable, 16 were severely disable, and 5 were left in the vegetative state. Evaluation of outcome of patients revealed that there was an overall mortality of 61 (46.9%) patients both in the acute phase and later. 33 of the 39 patients having Glasgow Coma Score (GCS) 3–5 at the time of EVD insertion expired, as against 20 of the 51 patients in GCS 6–8. Patients in GCS 9–12 had an even better outcome, with 8 of the 35 patients in this group expiring. Conclusions: The use of EVD should be undertaken only in situation where it is absolutely necessary and ventriculostomy should be kept only for the duration required, and this should be monitored on a daily basis, given the exponential increase in infection after 5 days.

Epidemiology of the neural tube defects in Kashmir Valley

Background: Neural tube defects (NTDs) are the most common congenital malformations affecting the brain and spinal cord and have a multifactorial etiology. Genetic and environmental factors have been found to cause these defects, both individually and in combination. Methods: A 2-year hospital-based prospective study was carried out from November 2013 to October 2015 to determine the incidence, types, demographics, risk factors, and other associated anamolies relevant to NTDs in Kashmir Valley. A detailed history of the mother was taken along with detailed clinical examination of neonate including measurement of head circumference and checking the status of fontanella, whether lax/full/bulging/or tense, type of NTD. Investigations that were done included were X-ray skull: Anterior-posterior (AP) and lateral, X-ray spine: AP and lateral, ultrasonography abdomen, magnetic resonance imaging: Spine and brain. Results: The total number of babies with NTDs was 125 with an overall incidence of 0.503. Kupwara district was having the highest incidence (1.047) and Srinagar district the lowest incidence of NTDs (0.197). Majority of NTDs (116 cases, 92.8%) were found in the rural areas. Among the different types of NTDs, spina bifida had an incidence of 0.342 (85 cases, 68%) and anencephaly had an incidence of 0.113 (28 cases, 22.4%). There was a slight preponderance of females over males with NTDs. There were 70 females (56%) and 55 males (44%), respectively, with a male: female ratio of 0.8:1 Conclusions: The incidence rates of NTDs is very high for Kashmir Valley. Geographical distribution of NTDs at this place confirms a relationship between the socioeconomic status, educational status, maternal too young or advanced age, and environmental factors for the development of a NTD. The results of this study point to the importance establishing a health policy to prevent NTD in Kashmir Valley.

Duodenal Perforation with an Unusual Presentation: A Case Report

A young female presented with classical complaints suggestive of peptic ulcer disease leading to signs of peritonitis. The said patient after being subjected to baseline workup was subjected to laparotomy which proved to be a surgical surprise. A live ascaris lumbricoides worm was seen pouting out of a duodenal perforation.

A unique case of calvarial hemangioma.

Background: Calvarial hemangiomas are one of the rarest neoplasms affecting the skull, predominantly occurring in parietal and frontal bones. Case Description: We report a parietal hemangioma in a middle-aged female which presented as a painless swelling that was progressively increasing in size and was treated surgically. Conclusion: Although rare, calvarial hemangioma should be a part of the differential diagnosis of calvarial swellings.

A rare case of recurrent primary spinal echinococcosis

Spinal hydatid disease, though rare, is one of the differential diagnosis of spinal cord compression syndrome especially in endemic areas. Surgery is the treatment of choice but surgery alone is not curative. Adjuvant drug therapy as well as intraoperative prophylaxis are indicated. Despite all measures, the disease has high recurrence rates and overall outcome is still poor. We report a case of 65 year old male with lumbosacral hydatidosis recurring after 13 years.

Coccygectomy for coccygodynia: A single center experience over 5 years

Introduction: Coccygodynia refers to a pathological condition in which pain occurs in the coccyx or its immediate vicinity. The pain is usually provoked by sitting or rising from sitting. Several studies have reported good or excellent results after coccygectomy especially in patients who are refractory to conservative treatment. Aims and Objectives: This study aims to evaluate the role and effectiveness of coccygectomy in chronic refractory coccygodynia. Materials and Methods: Between January 2011 and January 2015, 16 consecutive patients (4 males and 12 females) who underwent surgical coccygectomy were enrolled prospectively in the study. All patients suffered from treatment-resistant coccygodynia and had exhausted conservative therapeutic options for at least 6 months before undergoing surgery. The same surgeon performed a complete coccygectomy on all patients. Postoperative outcomes included measurements of pain relief and degree of patient satisfaction with the procedures results. Results: The average age of patient was 37.93 years (range: 25–53 years), and the male to female ratio was 1:3. The median duration of patient-reported symptoms prior to surgery was 24 months. The most common cause of coccygodynia was direct or indirect trauma, recorded in 11 patients (68.75%). Idiopathic coccygodynia was five cases (31.25%). The number of patients with outcomes rated as “excellent,” “good,” “fair,” and “poor” were 12, 2, 1, and 1, respectively. The favorable result (excellent or good) was 87.5%. The self-reported visual analog scale (VAS) was significantly improved by surgery. The mean VAS preoperatively was 9.62, and postoperatively it was 2.25 (P < 0.001). There were two infections (12.5%) among the 16 patients which were managed conservatively. Conclusions: Coccygectomy for chronic intractable coccygodynia is simple and effective, with a low complication rate.

Cranial Nerve Involvement in Brucellosis

Brucellosis is one of the common zoonotic infectious diseases in the world. It may involve all organs and systems. However, the central nervous system is unusually rarely involved. Meningitis is most frequently observed in neurobrucellosis and is associated with many complications like cranial nerve (CN) paralysis, meningoencephalitis, myelitis, radiculopathy, and neuropathy. Because of basal meningitis, one or more CN involvement is seen in more than 50 % of the patients with neurobrucellosis. Besides neurobrucellosis, causes of CN palsies in cases of brucellosis are pseudotumor cerebri and adverse reactions of tetracyclines which are used in the treatment of brucellosis.

Hydatids everywhere: A 15-year experience of unusual locations of the disease in an endemic area

Sir, Hydatid disease is a parasitosis, and it is endemic in many sheep-rearing regions in the world, especially in the Middle East and Mediterranean countries.[1-3] The reported annual morbidity from the disease in humans is 1.04-2.4 per 1,000,000, while the actual rates are supposed to be more than twice, this difference is probably due to the underreporting of data.[4] The liver (65-75%) and lungs (10-25%) are the organs most commonly involved, followed by peritoneal cavity (8-18%), spleen (2-3%), kidneys (14%), uterus and adnexa (0.5-1%), retroperitoneum (0.51%), pancreas (0.5-0.8%),[5] subcutaneous tissue (1-2%),[6] mediastinum (0.1-0.5%),[7] gall bladder (≤1%),[8] brain (2%),[9] seminal vesicle,[10] spinal cord,[11] and others (0.1-3%).[5]

Epidemiology of the neural tube defects in Kashmir Valley.

Introduction/Background: Neural tube defects (NTD) are the most common congenital malformations affecting the brain and spinal cord and have a multifactorial etiology. Genetic and environmental factors have been found to cause these defects, both individually and in combination. Aims and Objectives: The aim of this study was to determine the incidence, types, demographics, risk factors, and other associated anomalies relevant to NTDs in Kashmir Valley. Materials and Methods: A 2-year hospital-based prospective study was carried out from November 2013 to October 2015. A detailed history of the mother was taken along with detailed clinical examination of neonate including measurement of head circumference and checking the status of fontanella, whether - lax/full/bulging/or tense, type of NTD. Investigations that were done included were X-ray skull: Anteroposterior (AP) and lateral, X-ray spine: AP and lateral, ultrasonography abdomen, magnetic resonance imaging: Spine and brain. Results: The total number of babies with NTDs was 125 with an overall incidence of 0.503. District Kupwara was having the highest incidence (1.047) and district Srinagar the lowest incidence of NTDs (0.197). The majority of NTDs (116 cases, 92.8%) were found in the rural areas. Among the different types of NTDs, spina bifida had an incidence of 0.342 (85 cases, 68%), and anencephaly had an incidence of 0.113 (28 cases, 22.4%). There was a slight preponderance of females over males with NTDs. There were70 females (56%) and 55 males (44%) respectively with a male:female ratio of 0.8:1. Conclusions: The incidence rates of NTDs are very high for Kashmir Valley. Geographical distribution of NTDs at this place confirms a relationship between the socioeconomic status, educational status, maternal age and environmental factors for the development of an NTD. The results of this study point to the importance establishing a health policy to prevent NTDs in Kashmir Valley.

Hyponatremia in Postoperative Patients

Object: This study was done to evaluate the adverse effect of hyponatremia in post-operative patients, the clinical spectrum of complications and comparative study of these complications between the elderly patients (age > 50 years) and relatively young patients (age <50 years). Methods: The present’s study of clinical co-relation of hyponatremia in post-operative patients was carried out in 60 patients. The patients were taken from Department of Surgery. Patients were randomly selected and divided into two groups on the basis of age. Group 1, 50 years of age. All selected patients were asked for detailed history of illness and a complete physical and systemic examination was done. All baseline and other relevant investigation were done for confirmation of diagnosis and as pre-operative work up. Serum sodium and potassium was checked in all patients pre-operatively and only serum sodium was checked 24 hours and 48 hours post-operatively. Results: Significant number of patients post operatively developed hyponatremia (30%) and complications (30%) related to hyponatremia ranging from headache, nausea to altered sensorium. (p<0.05, statistically significant). The number of patients who developed post-operative hyponatremia as well as complications of hyponatremia was observed more in the patients who were more than 50 years of age (39.3%). Post-operative hyponatremia and related complications was observed more in patients who were having abdominal pathology like peritonitis and abdominal trauma, (33.3%) which was not statistically significant. Patients who were operated under general anesthesia (72.2%) developed more hyponatremia as compared to patients who were operated under local anesthesia or regional anesthesia (27.8%), which was statistically significant. Conclusion: We conclude that post- operative hyponatremia is not an uncommon post-operative complication and its progression to severe neurological manifestations like seizures, coma and eventual death can be prevented by anticipating hyponatremia in high risk patients, not confusing early manifestations with normal post-operative sequelae and treating hyponatremia as earlier as its symptoms appear.