Forhad Hossain Chowdhury

Brain abscess: surgical experiences of 162 cases

Aim: Brain abscess still poses a public health challenge in spite of the advent of modern neurosurgical techniques and antibiotics. Here, we present our surgical experiences and ultimate outcome in the management of brain abscess. Methods: Totally, 162 patients with proved brain abscess who underwent surgical treatment were included in this study. The prospectively recorded data of surgical management of brain abscess and the ultimate outcome (by Glasgow outcome scale) were studied retrospectively. Results: Total number of cases was 162, of which 113 were acute pyogenic abscess while 49 were chronic abscess. Among the chronic abscess, 29 were chronic pyogenic abscess, 14 were tubercular, 3 aspergillus, and 3 abscesses were in malignant brain metastases. In acute cases, common clinical features were headache, fever, vomiting, focal deficit and seizure. In chronic abscesses, common clinical features were mild to moderate headache and progressive focal deficit. Seventy-three (45.06%) patients had adjacent localized sinus, middle ear or cranial infection. The common predisposing factors included postneurosurgery, postpenetrating injury to brain, chronic suppurative otitis media, and congenital heart disease, infective endocarditis, sinusitis and sub optimum immuno-status. Frontal lobe involved in 30.2% cases, temporal lobe is next to involved. Single time burr hole aspiration in 111 (68.5%) cases, two or more times burr hole aspiration were done in 34 (21%) cases. Pus culture was negative in 129 (79.62%) cases. Total number of death was 22 (13.58%) cases. Complete resolution of abscess with complete recovery of preoperative neuro-deficit was seen in 80.86% cases and recovery with major neuro-deficit was observed in 5.55% cases. There is a significant association between Glasgow coma scale (GCS) on admission and mortality in brain abscess. Conclusion: In most of the cases, pus culture did not yield growth of any causative organism. Mortality was not directly related to surgical intervention, but GCS on admission has a significant association with mortality. Early diagnosis, optimum follow-up and timely surgical interventions are the keys in the proper management of brain abscess.

Condylar Joint Fusion and Stabilization (by Screws and Plates) in Nontraumatic Atlanto-Occipital Dislocation: Technical Report of 2 Cases

BACKGROUND Nontraumatic spontaneous atlanto-occipital dislocation (AOD) is rare. In this report, we discuss the technical steps of condylar joint fusion and stabilization (by screws and plates) in nontraumatic AOD. To the best of our knowledge, it is the first report of such techniques. MATERIAL AND METHODS A young girl and a young man with progressive quadriparesis due to nontraumatic spontaneous atlanto-occipital dislocation were managed by microsurgical reduction, fusion, and stabilization of the joint by occipital condylar and C1 lateral mass screw and plate fixation after mobilization of vertebral artery. RESULT In both cases, condylar joints fixation and fusion were done successfully. CONCLUSION Condylar joint stabilization and fusion may be a good or alternative option for AOD.

Cerebrum, Cerebellum, and Deep Structures of the Brain

Extensive and elaborative discussion of TB involving the cerebrum, deep structures of the brain, and cerebellum is beyond the scope of this chapter of the book. Every day the sciences are progressing in the knowing of TB of CNS. Available diagnostic tools and appropriate management protocol are continuously changing. In the management of cerebral and cerebellar TB, paradigm shifted toward the conservative drug therapy though surgery has its own definite role in the management of many cases, and sometimes it is lifesaving. Drug-resistant TB and cerebral and cerebellar TB in immunocompromised or immunosuppressed patients are very specially problematic with increased frequency of occurrence. For ease of discussion in this chapter, TB of cerebral hemisphere and deep structures of the brain (i.e., basal ganglia and parts of diencephalon) will be discussed together, and cerebellar TB will be discussed in the later part of the chapter. In this chapter all important aspects of cerebral and cerebellar TB including surgical aspects are discussed briefly.

Giant partially thrombosed 4th ventricular posterior inferior cerebellar artery aneurysm; microsurgical management

A 42-year-old woman presented with a 3-month history of progressive occipital headache, vomiting, walking difficulty, and repeated fall. She had no history of sudden and severe headache. She had positive cerebellar signs, predominantly on the right side. Computerized tomography (CT) scan, CT angiogram, and magnetic resonance image (MRI) of the brain showed suspected partially thrombosed giant 4 th ventricular posterior inferior cerebellar artery aneurysm. Patient developed severe hypersensitivity reaction during both CT scan and MRI after contrast injection. Though needed, digital subtraction angiogram (DSA) of cerebral vessels was not done. The aneurysm was managed by microsurgical clipping of the aneurysm neck and partial excision of thrombosed aneurysm. Here, we report the details of management of these difficult giant aneurysm without DSA.

Microsurgical management of benign lesions interior to the cavernous sinus: A case series

Background: Benign lesion interior to the cavernous sinus (CS) is very rare. Objective: In this series we found nonneoplastic lymphatic aggregation and osteoclastoma inside the CS which is very rare and probably not reported in literature. One interesting postoperative complaint of feeling of tickling down of warm water under the skin forehead was found in the patient of inflammatory disease of CS which is not reported in literature. Here we also describe our experiences of microsurgical management of series of benign lesions inside the CS. Materials and Methods: Benign mass originated from the content of CS or inner side of walls of CS, confirmed peroperatively were included in this series. Prospectively recorded data of microsurgical management was retrogradely studied. Results: Total number of patient was 12. Patients age range was 30–60 years. Follow-up range was 60 months to 19 months. Three was nonneoplastic lesion (tuberculosis, inflammatory and nonneoplastic lymphoid infiltration). Among the 9 neoplastic lesions, two hemangiomas, two meningiomas, three 6th nerve schwannomas, one osteoclastoma and one epidermoid tumor. Middle cranial fossa-subtemporal extradural approach was used in 9 cases and in two cases extended middle fossa zygomatic approach. New postoperative 3rd nerve palsy developed in 5 cases all recovered completely except one. In seven patients 6th nerve palsy developed after operation; only one recovered. Postoperatively simultaneous 3rd, 4th and 6th nerve palsy developed in four cases. One interesting postoperative complaint of feeling of tickling down of warm water under the skin of left sided forehead was found in the patient of inflammatory disease of CS. Mortality was nil. Total resection was done in 9 cases. There was no recurrence till last follow-up. Conclusion: Though decision for microsurgical removal of such lesions is not straight forward. Probably microsurgery is the best option in treating such benign lesions though it may associate with some permanent cranial nerve palsy.