B.S. Sharma

Neurocysticercosis: A review of current status and management

Neurocysticercosis (NCC) is an infection of the brain and its coverings by the larval stage of the tapeworm Taenia solium. It is the most common helminthic infestation of the central nervous system and a leading cause of acquired epilepsy worldwide. NCC induces neurological syndromes that vary from an asymptomatic infection to sudden death. Neuroimaging is the mainstay of diagnosis. The diagnosis is suggested in patients living in endemic areas with typical CT scan findings and a compatible clinical picture. Since the late 1980s, successful medical treatment has been established with relatively short courses of either albendazole or praziquantel. The selection of cases for medical or surgical treatments has improved and these two forms of therapy are complementary. In general, indications of surgery are: cysts that compress the brain and cranial nerves locally, intracranial hypertension or edema refractory to medical treatment, intraventricular NCC, spinal NCC with cord or root compression and ocular cysts. Recently, endoscopic approaches for ventricular NCC have been developed, which are now the treatment of choice for ventricular NCC with hydrocephalus.

Awake craniotomy versus surgery under general anesthesia for resection of intrinsic lesions of eloquent cortex—A prospective randomised study

OBJECTIVES Complete removal of a brain tumor without inflicting neurological deficits is a desirable end result in neurosurgical practice. Currently no prospective randomized surgical series in the literature exists comparing tumor resection under general versus local anesthesia awake surgery may achieve more aggressive tumor resection and minimize postoperative neurological morbidity. PATIENT AND METHODS We thence conducted a prospective randomized comparative study of results of surgery under awake versus surgery under general anesthesia for intrinsic eloquent area lesions. Fifty-three patients with intrinsic brain tumors in eloquent areas were prospectively randomized (26 patients in awake group and 27 for surgery under general anesthesia). At 3 months follow up, 23% patients in awake group had permanent deficits compared to 14.8% in GA group. RESULTS More than 90% tumor excision was observed in 57% patients in awake group versus 73.7% in GA group. CONCLUSIONS The mean operative time, blood loss was found to be was found to be less in GA group patients than in awake group. Better tumor cytoreduction, neurological improvement was seen in GA group (motor improvement in 35.7%, speech improvement in 62.5%) than in awake group patients (motor improvement in 18.7%, speech improvement in 14.3%).

Intra-operative electrocorticography in lesional epilepsy

Intra-operative electrocorticography (ECoG) is useful in epilepsy surgery to delineate margins of epileptogenic zone, guide resection and evaluate completeness of resection in surgically remediable intractable epilepsies. The study evaluated 157 cases (2000-2008). The preoperative evaluation also included ictal SPECT (122) and PET in 32 cases. All were lesional cases, 51% (81) of patients had >1 seizure/day and another 1/3rd (51) had >1/week. Pre and post resection ECoG was performed in all cases. A total of 372 recordings were performed in 157 cases. Second post-operative recordings (42) and third post-operative recordings (16) were also performed. Site of recordings included lateral temporal (61), frontal (39), parietal (37), hippocampal (16) and occipital (4). 129/157 cases (82%) showing improvement on ECoG, 30/42 cases showed improvement in 2nd post resection, 8/16 showed improvement in the 3rd post-operative ECoG. 116/157 (73%) patients had good outcome (Engel I and II) at follow up (12-94 months, mean 18.2 months). Of these, 104 patients (80%) showed improvement on post-operative ECoG. 12 had good outcome despite no improvement on ECoG. The improvement in ECoG correlated significantly with clinical improvement [Sensitivity: 100% (95% CI; 96-100%); specificity: 68.3% (95% CI; 51.8-81.4%); positive predictive value: 89.9% (95% CI, 83.1-94.3%); negative predictive value: 100% (95% CI, 85-100%)]. The level of agreement was 91.72% (kappa: 0.76). Concluding, pre and post resection ECoG correlated with its grade of severity and clinical outcome.

Distraction, compression, and extension reduction of basilar invagination and atlantoaxial dislocation: a novel pilot technique.

BACKGROUND The management of basilar invagination (BI) and atlantoaxial dislocation (AAD) is a challenge. OBJECTIVE To describe a new innovative method to reduce BI and AAD through a single-stage posterior approach. METHODS Thirty-five patients had irreducible BI and AAD (May 2010 to April 2012). In all patients, reduction of AAD and BI was achieved by using an innovative method of distraction and spacer placement, followed by compression and extension. A C1 lateral mass/C2 translaminar screw was performed in cases where the C1 arch was not assimilated, and occipito-C2 translaminar screw fixation was performed in cases where the C1 arch was assimilated. RESULTS Thirty-two of 35 (94%) patients improved clinically and 2 patients had stable symptoms (mean Nurick postoperative score = 1.4; preoperative score = 3.7). AAD reduced completely in 33/35 patients and >50% in 2. BI improved significantly in all patients. Solid bone fusion was demonstrated in 24 patients with at least 1-year follow-up (range, 12-39 months; mean, 19.75 + 7.09 months). The duration of surgery was 80 to 190 minutes, and blood loss was 90 to 500 mL (mean, 170 ± 35 mL). There was 1 death because of cardiac etiology and 1 morbidity (wound infection). CONCLUSION Distractive compressive extension and reduction of BI and AAD seems to be an effective and safe method of treatment. It is different from the earlier described techniques, because it is the first procedure that uses a spacer not, only for distraction, but also as a pivot to perform extension to reduce the AAD.

Giant pituitary adenomas—An enigma revisited. Microsurgical treatment strategies and outcome in a series of 250 patients

Background. Giant pituitary adenomas (> 4 cm) are a surgical challenge. We present our experiences in surgical management of these tumors in a series of 250 patients. Methods. Two hundred and fifty patients with giant pituitary adenomas were managed surgically at our center over last 13 years. Majority (92%) of patients presented with visual deterioration. Non-functioning tumors were found in 136 patients (54.3%). Among functioning adenomas, 63 patients (25.4%) had prolactinomas and 45 patients (18%) had GH-secreting adenomas; while 3 patients each had LH and ACTH- secreting adenomas. The maximum tumor diameter varied from 4 to 10.5 cm, with mean diameter of 5.4 cm. The factors determining choice of operative approach and surgical outcomes in these tumors were analyzed. Results. Overall, 273 surgical procedures were performed in 250 patients. Of these, 110 were transsphenoidal, while 163 were transcranial approaches. A single surgical procedure was performed in 227 patients (89.2%). 23 patients (9.2%) underwent re-exploration either because of postoperative apoplexy or residual tumor. Overall, near total (>90%) tumor excision could be achieved in 74%, with improved vision in 53% and good outcome in 75% patients. The mortality and morbidity were 4.4% and 14%, respectively. Conclusions. The main goal of surgical treatment of giant pituitary adenoma is maximum possible tumor extirpation with minimal side effects, which can be achieved by careful preoperative planning of operative approach, based on directions of tumor extensions and invasiveness. Maximal surgical removal of giant adenomas offers best chances to control tumor growth when followed with adjuvant medical and radiation therapies.

Gamma knife radiosurgery for glomus jugulare tumors: therapeutic advantages of minimalism in the skull base.

CONTEXT Glomus jugulare (GJ) tumors are paragangliomas found in the region of the jugular foramen. Surgery with/without embolization and conventional radiotherapy has been the traditional management option. AIM To analyze the efficacy of gamma knife radiosurgery (GKS) as a primary or an adjunctive form of therapy. SETTINGS AND DESIGN A retrospective analysis of patients who received GKS at a tertiary neurosurgical center was performed. MATERIALS AND METHODS Of the 1601 patients who underwent GKS from 1997 to 2006, 24 patients with GJ underwent 25 procedures. RESULTS The average age of the cohort was 46.6 years (range, 22-76 years) and the male to female ratio was 1:2. The most common neurological deficit was IX, X, XI cranial nerve paresis (15/24). Fifteen patients received primary GKS. Mean tumor size was 8.7 cc (range 1.1-17.2 cc). The coverage achieved was 93.1% (range 90-97%) using a mean tumor margin dose of 16.4 Gy (range 12-25 Gy) at a mean isodose of 49.5% (range 45-50%). Thirteen patients (six primary and seven secondary) were available for follow-up at a median interval of 24 months (range seven to 48 months). The average tumor size was 7.9 cc (range 1.1-17.2 cc). Using a mean tumor margin dose of 16.3 Gy (range 12-20 Gy) 93.6% coverage (range 91-97%) was achieved. Six patients improved clinically. A single patient developed transient trigeminal neuralgia. Magnetic resonance imaging follow-up was available for 10 patients; seven recorded a decrease in size. There was no tumor progression. CONCLUSIONS Gamma knife radiosurgery is a safe and effective primary and secondary modality of treatment for GJ.

Cystic acoustic neuromas: Surgical outcome in a series of 58 patients

We aimed to analyze the clinical characteristics and surgical outcomes of surgically treated cystic acoustic neuromas, and to determine the prognostic significance of the presence of cystic components, by comparing surgical outcomes for solid and cystic tumors. A total of 58 patients (20.4%) with newly diagnosed cystic tumor were studied. The surgical outcome was analyzed in terms of extent of tumor removal, facial nerve preservation, morbidity and mortality; and was compared with that in patients with solid tumors. Facial nerve preservation rates were much better for solid tumors (82.7%) than for cystic tumors (67.9%). The extent of tumor removal was complete in 75.9% of patients with cystic tumors as compared with 90.2% for solid acoustic neuromas. Overall mortality was 8.6%. Cystic tumors differ from solid acoustic neuromas by having a rapid growth pattern, short clinical history and more frequent facial nerve involvement. They are associated with a poorer surgical outcome in terms of facial preservation and overall result.

Transorbital penetrating cerebral injury with a ceramic stone: Report of an interesting case

Penetrating cranial injury is a potentially life-threatening condition. The majority of war injuries are high-velocity penetrating cranial injuries; but in civilian cases, most penetrating cranial wounds are low-velocity type. We report an interesting case of transorbital penetrating cranial injury with a knife-sharpening stone made up of ceramic in a 28-year-old male. The pertinent literature is reviewed and management of such cases is discussed.

Role of simvastatin in prevention of vasospasm and improving functional outcome after aneurysmal sub-arachnoid hemorrhage: a prospective, randomized, double-blind, placebo-controlled pilot trial

Abstract Background. Vasospasm plays a major role in the morbidity and mortality after aneurysmal subarachnoid hemorrhage (aSAH). The preliminary studies suggest that statins protect against cerebral vasospasm. Objective. The aim of the study was to determine the role of simvastatin in preventing clinical vasospasm and improving functional outcome in patients with aSAH. Methods. All patients with aSAH admitted within 96 h of ictus were randomized to receive either Simvastatin or placebo – 80 mg/day for 14 days. Thirty eight patients were recruited in the study- 19 received Simvastatin and 19 placebo. All the patients underwent surgical clipping of the aneurysm. The primary outcome of the study was the development of clinical cerebral vasospasm. The secondary outcomes included Glasgow Outcome Score (GOS), Modified Rankin Scale (MRS) and Barthel Index Score (MBI) at follow-up at 1, 3 and 6 months. Results. 16% of the patients in the simvastatin group had high Middle Cerebral Artery velocities (> 160 cm/sec) on transcranial Doppler on one or more than one day during the study duration as compared to 26% of the patients in the placebo group (p = 0.70). Neurological deterioration occurred in 26% and 42% of the patients in simvastatin group versus placebo group, respectively (p = 0.31). There was an improvement in the functional outcome in the simvastatin group at 1, 3 or 6 months in the follow-up; however, this difference was not statistically significant. Conclusions. There was benefit of simvastatin in terms of reduction in clinical vasospasm, mortality or improved functional outcome, however, this was not statistically significant.

Randomized controlled trial of magnesium sulphate in severe closed traumatic brain injury

Magnesium decline is likely to play an important role in the pathogenesis of Traumatic Brain Injury (TBI). This study was undertaken to test the therapeutic efficacy and safety of parenterally administered Magnesium sulphate (MgSO4) in patients of severe closed TBI. Adult patients admitted within 12 hours of closed TBI with Glasgow coma score 5 to 8 fulfilling eligibility criteria were randomized to two groups, one group receiving ‘standard care’ and the other, MgSO4 in addition as per the Pritchard regimen. The outcome measures were Glasgow outcome scale at 3 months and other relevant clinical parameters. Seventy patients were randomized after obtaining informed consent, and 30 in each group remained in the study till 3 months. Favorable outcome was observed in 22 out of 30 patients (73.3%) who had received MgSO4, as compared with 12 out of 30 (40%) in control group. Univariate analysis revealed an odds ratio (OR) of 4.13 (95% CI 1.39–12.27) and the P value was 0.009. In the logistic regression analysis, the adj. OR was 4.24 (95% CI 1.1–16.36) and the P value was 0.036. The secondary outcomes analyzed in MgSO4 group showed significant difference with respect to intra-operative brain swelling at the end of surgical decompression and mortality at 1 month. No significant adverse effects were observed. Parenteral MgSO4 appears to have some favorable influence on mortality and intra-operative brain swelling without any significant adverse effects.