Bijesh Ravindran Nair

Cerebral venous sinus thrombosis presentation in severe scrub typhus infection: a rare entity.

2. Yiğit A, Bingöl A, Mutluer N, Taşçilar N. The one‐and‐a‐half syndrome in systemic lupus erythematosus. J Neuroophthalmol 1996;16:274‐6. 3. Cogen MS, Kline LB, Duvall ER. Bilateral internuclear ophthalmoplegia in systemic lupus erythematosus. J Clin Neuroophthalmol 1987;7:69‐73. 4. Dutta I, Gohar S, Balakrishnan C, Mangat G, Mittal G, Bhaba SK, et al. Unilateral inter‐nuclear ophthalmoplegia in systemic lupus erythematosus. J Assoc Physicians India 2000;48:1210‐1. 5. Galindo M, Pablos JL, Gomez‐Reino JJ. Internuclear ophthalmoplegia in systemic lupus erythematosus. Semin Arthritis Rheum 1998;28:179‐86. 6. Jackson G, Miller M, Littlejohn G, Helme R, King R. Bilateral internuclear ophthalmoplegia in systemic lupus erythematosus. J Rheumatol 1986;13:1161‐2. 7. Keane JR. Eye movement abnormalities in systemic lupus erythematosus. Arch Neurol 1995;52:1145‐9. 8. Efthimiou P, Blanco M. Pathogenesis of neuropsychiatric systemic lupus erythematosus and potential biomarkers. Mod Rheumatol 2009;19:457‐68.

Complications following central corpectomy in 468 consecutive patients with degenerative cervical spine disease

OBJECTIVE This study was performed to describe the incidence and predictors of perioperative complications following central corpectomy (CC) in 468 consecutive patients with cervical spondylotic myelopathy (CSM) or ossification of the posterior longitudinal ligament (OPLL). METHODS The authors performed a retrospective review of a cohort of patients who had undergone surgery for CSM (n = 338) or OPLL (n = 130) performed by a single surgeon over a 15-year period. All patients underwent uninstrumented CC with autologous iliac crest or fibular strut grafting. Preoperative clinical and imaging details were collected, and the type and incidence of complications were studied. Univariate and multivariate analyses were performed to establish risk factors for the development of perioperative complications. RESULTS Overall, 12.4% of patients suffered at least 1 complication following CC. The incidence of major complications was as follows: C-5 radiculopathy, 1.3%; recurrent laryngeal nerve injury, 0.4%; dysphagia, 0.8%; surgical-site infection, 3.4%; and dural tear, 4.3%. There was 1 postoperative death (0.2%). On multivariate analysis, patients in whom the corpectomy involved the C-4 vertebral body (alone or as part of multilevel CC) were significantly more likely to suffer complications (p = 0.004). OPLL and skip corpectomy were risk factors for dural tear (p = 0.015 and p = 0.001, respectively). No factors were found to be significantly associated with postoperative C-5 palsy, dysphagia, or acute graft extrusion on univariate or multivariate analysis. Patients who underwent multilevel CC were predisposed to surgical-site infections, with a slight trend toward statistical significance (p = 0.094). The occurrence of a complication after surgery significantly increased the mean duration of postoperative hospital stay from 5.0 ± 2.3 days to 8.9 ± 6 days (p < 0.001). CONCLUSIONS Complications following CC for CSM or OPLL are infrequent, but they significantly prolong hospital stay. The most frequent complication following CC is dural tear, for which a diagnosis of OPLL and a skip corpectomy are significant risk factors.

Clinical, imaging and histopathological features of isolated CNS lymphomatoid granulomatosis.

Lymphomatoid granulomatosis is a rare systemic angiocentric/angiodestructive, B cell lymphoproliferative disorder. Central nervous system involvement occurs as part of systemic disease. Isolated central nervous system disease is rare with only few case reports. A 53-year-old male presented with progressive cognitive decline, extrapyramidal features, and altered sensorium with seizures over the last 4 years. His magnetic resonance imaging (MRI) of brain showed multiple small enhancing nodules in subependymal/ependymal regions and along the vessels. Brain biopsy showed atypical lymphohistiocytic infiltrate suggestive of lymphomatoid granulomatosis. There was no evidence of systemic disease; thus, isolated central nervous system lymphomatoid granulomatosis was diagnosed.

Importance of fibrinogen in dilutional coagulopathy after neurosurgical procedures: A descriptive study

Background and Aims : The routine management of coagulopathy during surgery involves assessing haemoglobin, prothrombin time (PT), activated partial thromboplastin time (aPTT) and platelets. Correction of these parameters involves administration of blood, fresh frozen plasma and platelet concentrates. The study was aimed at identifying the most common coagulation abnormality during neurosurgical procedures and the treatment of dilutional coagulopathy with blood components. Methods : During 2 years period, all adult patients undergoing neurosurgical procedures who were transfused two or more units of red cells were prospectively evaluated for the presence of a coagulopathy. PT, aPTT, platelet count and fibrinogen levels were estimated before starting a component therapy. Results : After assessing PT, aPTT, platelet count and fibrinogen levels following two or more blood transfusions, thirty patients were found to have at least one abnormal parameter that required administration of a blood product. The most common abnormality was a low fibrinogen level, seen in 26 patients; this was the only abnormality in three patients. No patient was found to have an abnormal PT or aPTT without either the fibrinogen concentration or platelet count or both being low. Conclusion : Low fibrinogen concentration was the most common coagulation abnormality found after blood transfusions for neurosurgical procedures.

Primary Intradural Extramedullary Cervical Spinal Cysticercosis

BACKGROUND Spinal cysticercosis has been reported in 0.7%-3.0% of patients with neurocysticercosis. Most patients with spinal cysticercosis have a coexisting intracranial disease. Most often this intracranial disease manifests as intradural extramedullary lesions involving thoracic and lumbar regions or intramedullary lesions. Intradural extramedullary primary spinal cysticercosis manifesting as cervical myelopathy is extremely rare and has not been reported to date. CASE DESCRIPTION A 56-year-old man from the northeastern part of India presented with progressive spastic quadriparesis. Magnetic resonance imaging showed a ventrally located intradural extramedullary multiloculated cyst with an enhancing wall in the upper cervical region. Enzyme-linked immunoelectrotransfer blot performed to detect cysticercal antibodies in serum was positive. The patient underwent total excision of the cysts, which were confirmed histologically to be cysticercal cysts. He was also treated with 2 weeks of albendazole therapy after surgery. He had recovered fully 1 year later. CONCLUSIONS Cysticercosis should be considered in the differential diagnosis in a patient with multiloculated cysts in the spinal subarachnoid space. Surgical exploration and excision of the cysts should be performed not only to establish a diagnosis but also to decompress the cord before medical therapy.

An adult with atrial septal defect presenting with a brain abscess

The common heart diseases resulting in a brain abscess are associated with a right to left shunt and include tetralogy of Fallot and transposition of great vessels. Atrial septal defect (ASD) is almost always associated with the left to right shunt and therefore is not a commonly considered risk factor for brain abscess. We report the case of a 29-year-old male, with no symptoms of cardiac disease, who presented with the left posterior frontal pyogenic abscess which led to the detection of a silent ASD. Our case emphasizes the need for a careful evaluation of the source of infection in patients with a brain abscess.

Tale of a tooth

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Rhabdomyolysis in lumbar spinal surgery: Early detection is crucial

Sir, Rhabdomyolysis (RM) after neurosurgical procedure is a rare event. We report a case of RM following lumbar surgery and discuss the importance of early recognition. A 22-year-old male underwent resection of L3 giant cell tumor in right lateral position. The patient weighed 96 kg with a body mass index (BMI) of 35.6 kg/m2 with no comorbidities. General anesthesia was administered with oxygen, nitrous oxide, isoflurane, propofol, and morphine. Surgery lasted for 9 h. On 1st postoperative day, he developed severe pain with a progressive increase in girth of the right thigh. Doppler study ruled out deep venous thrombosis. Next day, he developed tachycardia, tachypnea, and icterus. Concurrently, he had oliguria. Investigations showed a high serum creatinine (1.63 mg/dl), creatine phosphokinase (CPK) (29,100 U/L) and deranged liver function (total bilirubin 1.5 mg%, direct 0.5 mg%, aspartate aminotransferase 209 U/L, alanine aminotransferase 185 U/L, alkaline phosphate 372 U/L). A diagnosis of RM was made, and the patient was treated with liberal hydration to maintain urine output of at least 100 ml/h along with alkalinization of urine. Clinically and serologically, he started to improve and was ambulated and discharged in a week. There are only a few reported cases of RM after neurosurgical procedures, with several risk factors being proposed. Lateral positioning in posterior fossa tumor resection and minimally invasive spinal surgeries have been reported as probable cause in 9 patients.[1] Van Gompel et al. reviewed 10 cases of RM after neurosurgery in supine or prone positions for cranial and spinal pathologies, and found obesity and prolonged surgery as common risk factors.[2] Woernle et al. studied 150 patients with routine CPK analysis before and after surgery to determine the effect of position. They correlated raised CPK not only with lateral position, but also with the use of intraoperative monitoring, and hypothesized it to be due to the absence of pharmacological relaxation during monitoring.[3] In our case, several of these factors contributed to the development of RM. The patient was obese (BMI of 35.8 kg/m2), had a long surgery (9 h) in right lateral position. Use of isoflurane is thought to stress an unstable sarcolemmal membrane causing increased permeability resulting in an influx of calcium and leak of intracellular potassium and creatinine kinase from myocytes.[4] Acute renal failure (ARF) is the most dangerous complication of RM, with prompt recognition and early therapy determining the outcome. Adequate rehydration to maintain hourly urine output of 100–300 ml is the main component of management to prevent ARF, with alkalization of urine to maintain pH >7.5. The kidney disease improving global outcomes recommends against the use of diuretics to maintain an adequate output (level 1 B).[5] Hemodialysis is required if the kidneys do not respond. Rhabdomyolysis is a rare but potentially life-threatening postoperative complication in neurosurgery, with obesity, lateral position, and prolonged surgery being common risk factors. A high index of suspicion and early recognition helps prevent renal shutdown.

Cervical intramedullary schwannoma mimicking a glioma

We present a case of a cervical intramedullary schwannoma (IS), which resembled a glioma on radiology. Somatic and root pain, the most common presenting complaints of IS, were lacking in our patient, and the characteristic magnetic resonance finding of an enhancing thickened nerve root in IS, was absent in our case. Preoperative diagnosis of a cervical IS is not always possible. Complete tumor resection is the ideal treatment for IS. Intraoperative frozen section can be a useful for decision making though the tumor-cord plane will ultimately decide if the tumor can be radically excised.

Bilateral pupillary dilatation with normal intracranial pressure

Sir, The standard management of non-operable severe head injury is ventilation with intracranial pressure (ICP) monitoring (brain trauma foundation).[1] Since the patient is often sedated for ventilation, neurological monitoring is restricted to examination of the pupils. We report the case of a patient who almost forced a fundamental change in our management protocol. A 50-year-old diabetic female patient was admitted 2 h following a road traffic accident with a Glasgow coma scales core of 8/15, minimally asymmetric, but briskly reacting pupils and no lateralizing deficit. A computerized tomography (CT) scan of the brain showed bilateral frontal and a small right temporal contusion with preserved basal cisterns [Figure 1]. She was managed conservatively with ventilation and ICP monitoring. The ICP remained below 15 mmHg for the 1st 3 days and then showed a minimal increase up to a maximum of 18 mmHg. It was therefore decided to repeat a CT scan before weaning from the ventilator. The CT scan was performed 76 h after the trauma showed resolving contusions with increased edema around them [Figure 2]. Hence, mannitol was started and later vasopressors were added to maintain an adequate cerebral perfusion pressure. Figure 1 Axial computerized tomography scan 3 h following trauma showing bilateral frontal contusions adjacent to the falx with some surrounding edema. cerebrospinal fluid cisterns are seen Figure 2 Computerized tomography scan 3 days later showing a decrease in the volume of hemorrhage and an increase in the edema. CSF cisterns are better visualized than in the earlier scan At 16 h after the second scan, her pupils became large and non-reacting, though ICP remained below 20 mmHg. Assuming the ICP values were wrong, patient was taken up for a bifrontal decompressive craniectomy. After craniectomy, dura and brain were lax, excluding raised ICP. After craniectomy, blood pressure dropped further and had severe metabolic acidosis with a pH of 6.91 and a chloride of 123 mmol/L. Despite vigorous treatment of acidosis, blood pressure never recovered and she died 4 h later. This report highlights the importance of hemodynamic changes and escalating needs of vasoactive drugs while managing a severe head injury with ICP monitoring. The hypotension was assumed to be due to the effects of acidosis on the heart and vasculature.[2] Though hyperchloremic acidosis is not fatal, Kellum et al. have reported that saline resuscitation significantly shortened survival. The survival time inversely correlated with the decrease in pH and the rise in serum chloride.[3] Ritter et al. demonstrated reduced blood flow in the midbrain in patients with pupillary dilatation, independent of the ICP and brainstem lesions on CT scan and concluded that brainstem ischemia was an important causal factor in pupillary dilatation.[4] It is possible that the severe acidosis could have caused local vascular changes in the region of brainstem in our patient resulting in pupillary dilatation since there were no clinical or surgical features of raised ICP or herniation. In conclusion, we wish to reiterate that pupillary changes in head injury need not always be caused by herniation. This case also shows that excessive importance given to one parameter (in our case, ICP) can result in decreased attention to other equally important clinical and laboratory findings and less than optimal care.