Au Ramzan

Evaluation of hyperglycaemic response to intra-operative dexamethasone administration in patients undergoing elective intracranial surgery: A randomised, prospective study

Background and Aim: The glucocorticoid dexamethasone in a bolus dose of 8-10 mg followed by quarterly dose of 4 mg is commonly used during intracranial surgery so as to reduce oedema and vascular permeability. However, the detrimental hyperglycaemic effects of dexamethasone may override its potentially beneficial effects. The present prospective, randomised study aimed at comparing the degree and magnitude of hyperglycaemia induced by prophylactic administration of dexamethasone in patients undergoing elective craniotomy. Materials and Methods: Sixty American Society of Anaesthesiologist (ASA) grade-I and II patients were randomly assigned to three groups of 20 patients each. Group-I received dexamethasone during surgery for the first time. Group-II received dexamethasone in addition to receiving it pre-operatively, whereas Group-III (control group) patients were administered normal saline as placebo. Baseline blood glucose (BG) was measured in all the three groups before induction of anaesthesia and thereafter after every hour for 4 h and then two-hourly. Besides intra- and intergroup comparison of BG, peak BG concentration was also recorded for each patient. Statistical analysis was carried out with analysis of variance (ANOVA) and Students t-test and value of P < 0.05 was considered statistically significant. Results: Baseline BG reading were higher and statistically significant in Group-II as compared with Group-I and Group-III (P < 0.05). However, peak BG levels were significantly higher in Group-I than in Group-II and III (P < 0.05). Similarly, the magnitude of change in peak BG was significantly higher in Group-I as compared to Group-II and III (P < 0.05). Conclusion: Peri-operative administration of dexamethasone during neurosurgical procedures can cause significant increase in BG concentration especially in patients who receive dexamethasone intra-operatively only.

Dural-stabs after wide craniectomy to decompress acute subdural hematoma with severe traumatic brain edema — An alternative technique to open dural flap

Abstract The Department of Neurosurgery Sher-i-Kashmir Institute of Medical Sciences (SKIMS) Srinagar, a single neurosurgical centre in Kashmir valley, assessed prospectively, under a uniform protocol, 120 patients of severe traumatic brain edema with acute subdural hematoma by wide decompressive craniectomy with dural-stabs in 60(cases) patients as against conventional dural opening (open dural flap) and removal of acute subdural hematoma in 60(controls) patients during a period of 3 years (June 2006 to June 2009). A free bone flap was elevated and preserved. All patients had GCS (Glassgow Coma Scale) score of 8 and less. The elective ventilation and ICP monitoring was carried out in all patients. Most patients were young and males with a mean age of 30 years in both groups. The overall survival of the dural-stab group (case-study) was 78.3% with good recovery in 43.3% and a mortality of 21.6% (13/60) as compared to 40% survival in open dural flap (control) group with 11.6% good recovery and a mortality of 60% (36/60). The conventional (open dural flap) procedure to remove the clot proved dangerous in a traumatic “vent-searching” and edematous brain, restricted in a rigid cranial vault. This midway-approach, known in SKIMS as “dural-stabs”, between the only decompressive craniectomy and removal of acute subdural clot by open dural flap (conventional) method, proved much effective in increasing survival of low GCS and severe traumatic brain edema with acute subdural hematoma. In conclusion decompressive craniectomy alone is not sufficient and open dural flap is full of risk in such patients.

Gluteal pseudophallus in a male child: A rare cutaneous marker of occult spinal dysraphism

Congenital midline paraspinal cutaneous markers have been practically linked to the location and nature of neural-tissue lesions. One of the most interesting congenital midline paraspinal cutaneous markers has been the human tail in the lumbosacral region, with underlying spinal dysraphism. Human tails have many shapes and sizes and are usually localized to the lumbosacral region. After a complete neurological examination, the MRI is the most sensitive diagnostic modality to reveal the underlying occult spinal dysraphic state. Surgical excision is aimed at untethering of the spinal cord in symptomatic children and for aesthetic reasons in asymptomatic patients. Here we report an asymptomatic male child with normal external genitilia, whose tail is attached to the gluteal region like an adult phallus and investigations revealed an underlying spinal dysraphic state.