D. I. Bhat

Stereotactic biopsy of brainstem lesions: Techniques, efficacy, safety, and disease variation between adults and children: A single institutional series and review

Background: Stereotactic biopsy of brainstem lesions have been performed with varying indications, with most of the literature reporting on children. Materials and Methods: The present study retrospectively analyzed all cases that underwent stereotactic biopsy for brainstem lesion in both adult and pediatric population between 1994 and 2009 in a single tertiary neurosurgical center. The clinical and radiological features, technique of the procedure, morbidity, diagnostic accuracy, spectrum of diagnosis, and variations in adult and pediatric population were analyzed. Results: Eighty-two patients were included in the study. Computed tomography (CT) was used as guidance in 73 (38 children and 35 adults) patients and magnetic resonance imaging (MRI) in 9 (3 children and 6 adults). The biopsy was performed in a procedure room under local anesthesia in most adults, while children required sedation. Glioblastoma comprised 29.3% of all pathologies in children, compared with only 4.9% of the pathologies in adult population (P = 0.007). Tuberculosis was the next major diagnosis (9.8%). In 12 patients, initial biopsy was inconclusive. Following a repeat biopsy in 5 of these patients, a diagnosis was possible for 75/82 (91.5%) patients by STB. The location of the target, the choice of entry, the radiological characteristic of the lesion, enhancement pattern, and age group did not significantly correlate with the occurrence of inconclusive biopsy. Permanent complications occurred in two patients (2.4%). There was no mortality in this series. Conclusion: Stereotactic biopsy has an important role in brainstem lesions, more significantly in adults, due to wider pathological spectrum. It can be performed safely under local anesthesia through a twist drill craniostomy in most of the adults.

A rare vascular complication of transsphenoidal surgery

We report a rare case of anterior cerebral artery (ACA) thrombosis following transsphenoidal surgery in a case of growth hormone secreting pituitary macroadenoma. During the surgery, there was arachnoid breach with cerebrospinal fluid (CSF) leak. Post operatively, she became blind in both eyes for which re-exploration was done. A computed tomographic (CT) scan 16xa0hours after surgery showed a large tumor bed haematoma which was explored transcranially. During surgery, the right A1 was thrombosed while the ICA and middle cerebral artery (MCA) were patent as confirmed by post-operative magnetic resonance imaging (MRI). However, she died on the second post-operative day. ACA thrombosis following transsphenoidal surgery has not been reported before. A review of literature and possible mechanism of this complication has been discussed.

Aggressive management of vasospasm with direct intra-arterial nimodipine therapy

Background: The conventional medical management of cerebral vasospasm following aneurysmal subarachnoid hemorrhage (SAH) is associated with uncertainty of outcome and complications. Aims and Objectives: To examine the effect of direct intra-arterial nimodipine therapy on outcome in patients with delayed cerebral ischemia (DCI). Settings and Design: The retrospective observational study was conducted at a single neurosurgical unit and interventional neuroradiolgy suite of a center managing SAH. Materials and Methods: Data analysis of SAH managed surgically during the period from January 2014 through October 2015 was performed. Any decline in the neurological status on clinical examination, such as consciousness, motor and speech deficits, without other identifiable causes such as hydrocephalus, hyponatremia, seizure, intracranial hematoma, or infection, was used to define the presence of DCI. Patients with suspected DCI underwent computed tomography (CT) scan of the head followed by angiography. When vasospasm was detected in the absence of any major arterial territory infarct, the patients were managed with intra-arterial nimodipine therapy. The outcome at discharge was assessed. Statistical Analysis: Mid-P exact, two-tailed P value was used for categorical variables. Results: A total of 106 patients underwent surgical clipping of an aneurysm following SAH. DCI was diagnosed in 26 (24.5%) patients. Twenty three (88.5%) patients underwent intra-arterial nimodipine therapy. Angiographic response was seen in 22 (95.7%) patients and clinical response in 20 (87%) patients. At discharge, 19 patients (73.1%) with vasospasm had a favorable outcome. There was no significant difference in the outcome of patients with or without vasospasm. Conclusions: Aggressive management with intra-arterial nimodipine therapy is effective in preventing disability caused by DCI.

Post-traumatic cervical spondyloptosis: A rare entity with multiple management options

Post-traumatic cervical spondyloptosis is a rare condition associated with high energy injuries, and to our knowledge only case reports are available. There are no universally accepted treatment paradigms for these cases and management is individualised according to the case and surgeon preference. We retrospectively analysed our management and clinical outcomes of this condition. From January 2007 to August 2014 we treated eight patients with cervical spondyloptosis at our institute. Only two patients had no neurological deficits; all the remaining patients had partial cord injury. Seven were treated surgically with preoperative traction followed by anterior cervical discectomy and fusion with fixation in three patients, and combined anterior and posterior fusion and fixation in four. Depending on the presence of anterior compression by a disc an anterior first or posterior first approach was advocated. All four combined anterior and posterior fusion and fixation patients needed to be turned more than once (540°). There was no neurological deterioration in any of the patients, as they either improved or remained stable neurologically. Post-traumatic cervical spondyloptosis is a challenging entity to manage. Surgery can be done safely with good clinical and radiological outcome and needs to be tailored to the individual patient.