Deepti Bhargava

Lumbar Drainage of Cerebrospinal Fluid After Aneurysmal Subarachnoid Hemorrhage: A Prospective, Randomized, Controlled Trial (LUMAS)

Background and Purpose— A single-center prospective randomized controlled trial has been conducted to determine if lumbar drainage of cerebrospinal fluid after aneurysmal subarachnoid hemorrhage reduces the prevalence of delayed ischemic neurological deficit and improves clinical outcome. Methods— Patients with World Federation of Neurological Surgeons Grade 1 to 3 aneurysmal subarachnoid hemorrhage and modified Fisher Grades 2, 3, 4, and 3+4 were randomized to either the study group of standard therapy plus insertion of a lumbar drain or the control group of standard therapy alone. The primary outcome measure was the prevalence of delayed ischemic neurological deficit. Results— Two hundred ten patients with aneurysmal subarachnoid hemorrhage (166 female, 44 male; median age, 54 years; interquartile range, 45–62 years) were recruited into the control (n=105) and study (n=105) groups of the trial. World Federation of Neurological Surgeons grade was: 1 (n=139), 2 (n=60), and 3 (n=11); Fisher grade was: 2 (n=87), 3 (n=85), and 4 (n=38). The prevalence of delayed ischemic neurological deficit was 35.2% and 21.0% in the control and study groups, respectively (P=0.021). The prevalence of a modified Rankin Scale score of 4, 5, or 6 at Day 10 and 6 months, respectively, was 62.5% and 18.6% in the control group and 44.8% and 19.8% in the study group (P=0.009 and 0.83, respectively). Conclusions— Lumbar drainage of cerebrospinal fluid after aneurysmal subarachnoid hemorrhage has been shown to reduce the prevalence of delayed ischemic neurological deficit and improve early clinical outcome but failed to improve outcome at 6 months after aneurysmal subarachnoid hemorrhage. Clinical Trial Registration— URL: www.clinicaltrials.gov. Unique identifier: NCT00842049.

Construction of titanium cranioplasty plate using craniectomy bone flap as template.

In recent times a steady rise in cranioplasty operations has been noted because of increasing utilisation of decompressive craniectomy for trauma as well as stroke patients. A variety of techniques have been utilised for cranioplasty, with their own benefits and limitations. Titanium cranioplasty is one of the well-established and widely used techniques, with most centres utilising computer-assisted reconstruction for manufacture of titanium plates. In this paper we present a novel method for making titanium cranioplasty plates using the craniectomy bone flap as a template and the results of our experience. To date we have performed 51 cranioplasties using this method. The surgical results have been comparable to those obtained using the computer-assisted model technique. The construction cost for titanium cranioplasty plates using this method has been £360 cheaper per plate compared with the computer-assisted method. In addition, the CT workload and radiation exposure have been reduced.

Occurrence and distribution of pilomyxoid astrocytoma

Abstract Purpose. To know the occurrence and distribution of Pilomyxoid Astrocytomas amongst tumours previously diagnosed histologically as Pilocytic Astrocytoma and to assess the clinical impact of this new entity. Methods. Retrospective Diagnostic review of all cases histologically diagnosed as WHO Grade I Astrocytoma at a single Neurosurgical unit between 1990 and 2003. Results. Of a total of 91 cases identified, 9 were found to have Pilomyxoid histology. Of these, 8 were children (mean age 3.33 years) and 1 adult. 6 tumours were hypothalamochiasmatic in location. The clinical course of Pilomyxoid tumours was aggressive marked by maturation, multiple recurrences and disease control was rarely achieved with single treatment modality as opposed to typical pilocytics. The overall survival of the pilomyxoid group was not statistically different from the pilocytic tumours. Conclusions. Encompassing all age-groups and locations, Pilomyxoid Astrocytomas constitute about 10% of all tumours previously diagnosed as Pilocytic Astrocytoma. Nearly two-thirds are hypothalamo-chiasmatic in location. Knowledge of this entity is essential for appropriate aggressive treatment and follow-up.

Surgical Outcome for Foot Drop in Lumbar Degenerative Disease

Controversy exists regarding the timing and outcome of surgery for lumbar degenerative disease (LDD) associated with foot drop. In this work, we report the results of a retrospective observational study from our center. We had a sample size of 26 patients with a minimum follow-up of 6 months. Of the 26 patients, 88% improved, with complete recovery observed in 61%. Thus, our data support the view that there is good recovery from operative management of foot drop secondary to LDD. Adjusting for preoperative strength, preoperative duration of weakness was a significant predictor of extent of recovery (odds ratio = 0.93; 95% confidence interval 0.88 to 0.98; p = 0.019). The model explained 50% of the variance in outcome in this study.

New Modalities to Assess Efficacy of Triple-H Therapy: Early Experience

The traditional axiom that vasospasm induced reduction of blood flow leads to poor tissue oxygenation and ischaemic cellular injury culminating in delayed neurological deficits has been challenged and the efficacy of triple H therapy in reversal of the above is debated. In this study we assess cerebral physiology before and during onset of DIND and with application of triple H therapy with real time neuro-monitoring tools. Patients with Fisher grade 3/4/3 + 4/rebleed were consented. Probes for measuring rCBF, pTiO2, and Microdialysis parameters - glucose, glycerol, lactate, and pyruvate were inserted at time of coiling/clipping. Subsequent monitoring was done in HDU/ITU setting. Return of parameters to baseline was regarded as effective triple H therapy. Study is ongoing and the current paper presents our experience with first five patients. The results suggest safety and feasibility of multimodal monitoring in clinical setting to establish an understanding of relationship between clinical symptoms, brain perfusion, oxygenation, and metabolism in real time to test and guide therapy in future.

Identifying patient report outcomes relevant to aneurysmal subarachnoid hemorrhage follow-up.

Patients recovered from subarachnoid hemorrhage can be assessed for neuropsychological dysfunction using postal questionnaires. We assessed 214 patients using various tests of memory, mood and strategic thinking. Patients in good outcome categories (modified Rankin Scale [mRS] 0-1) nevertheless exhibited mood disorder (28%), memory deficit and executive dysfunction (20%). Return to work (49%) was most influenced by previous employment status, Rankin scale and mood.

Size does matter

Urethral calculi could be either classified as either primary or secondary calculi based on their origin. Primary calculi form in the urethra, whereas secondary calculi have their origin elsewhere in the urinary tract.1 True primary calculi are rare and they mostly form in prostatic and membranous …

Response to letter by Dr. Fathi and colleagues

Dear Sir, We thank Dr. Fathi and colleagues for their interest and comments on our paper. There are several alternatives for skull reconstruction, and each of them have their indications, benefits and limitations with the onus of responsibility being on the surgeon to decide what best applies to a specific case scenario. Our paper describes an alternative technique for manufacture of titanium cranioplasty plates. We acknowledge, as in the original paper, that limitation of this technique is that an intact bony template is needed, and hence, this technique may only be used for delayed reconstruction in cases where intact bone is available, hence making it unsuitable for open skull fractures, bone flap tumour invasion and calcified hematomas, etc. In these cases, PMMA reconstruction recommended by Dr. Fathi is currently used in our centre as well. However, with aggressive management of head injury and malignant stroke, decompressive craniectomy has evolved as the major indication for cranioplasty. For these cases needing delayed reconstruction, titanium offers certain advantages above other materials [references 1, 6, 7, 13, 18, and 22 in original paper (1)], hence, the role for our technique.