Gohar Javed

Traumatic retroclival epidural hematoma in pediatric patient-Case report and review of literature.

Background: Retroclival epidural hematoma (REDH) is a very rare entity in the practical field of neurosurgery. Only a few cases have been reported in literature. The authors present to you case of a 12-year-old female, a victim of road traffic accident (RTA), who had presented to us with loss of consciousness and seizures. Case Description: Magnetic resonance imaging revealed retroclival hematoma. She was managed on conservative grounds and discharged with assurance of multiple follow-up visits. Conclusion: Very few cases of REDH have been reported in pediatric population to date. It should be suspected in children with head and neck injuries who have been a victim of RTAs. Most likely underdiagnosed due to its rarity; therefore, MRI should be considered when the suspicion is high. Atlanto-occipital dislocation should always be kept under consideration in all cases, and therefore should be managed and monitored very cautiously. In this report, the authors also present concise review of the literature pertaining to the pathogenesis and management of this rare clinical entity which has a high likelihood to be encountered and underdiagnosed by neurosurgeons in Emergency Room.

Lumbar morphometry: a study of lumbar vertebrae from a pakistani population using computed tomography scans.

Study Design A cross-sectional study. Purpose To describe the characteristics of lumbar vertebrae of Pakistani patients reporting at a tertiary care hospital and compare with studies from other populations. Overview of Literature Several studies have been conducted to determine morphometry of lumbar vertebrae. Most of the studies involve Caucasian populations, still data on other populations still sparse. This is the first study describing lumbar morphometry of a Pakistani population. Methods An observational study was conducted based on a review of thin-cut (3 mm) computed topographic images of lumbar vertebrae. Two-hundred and twenty vertebrae from forty-nine patients were studied, and various dimensions were analyzed. Results Generally, the size of the vertebrae, vertebral canals and recesses were found to be greater in male patients. The difference was statistically significant for transverse and anteroposterior diameters of the vertebral bodies and sagittal diameter of pedicles on the left side (p<0.05). Comparison of populations revealed statistically significant differences in pedicle dimensions between Pakistani population and others. Conclusions This study provides anatomical knowledge of the lumbar region in a sample population of Pakistan. There were significant differences in various dimensions of lumbar vertebrae between female and male patients. This would prove to be critical for performing a safe operation.

Low-grade small round cell tumor of the cauda equina with EWSR1-WT1 fusion and indolent clinical course

We report a case of a longstanding, large tumor involving spinal nerve roots of the cauda equina. The tumor showed small round cells arranged in nests and cords and immunophenotypic features of a glomus tumor, along with infrequent mitoses and a low Ki-67 labeling index, but exhibited some rosette-like structures, with focal CD99 and Neu-N expression. Subsequent molecular analysis showed the presence of an EWSR1-WT1 gene fusion by fluorescence in situ hybridization, which was confirmed by reverse- transcriptase polymerase chain reaction. To our knowledge, this is the first case reported with EWSR1-WT1 fusion in a small round blue cell tumor with smooth muscle differentiation and an indolent course.

Comparison of Irrigation versus No Irrigation during Burr Hole Evacuation of Chronic Subdural Hematoma.

Objective To compare the results of the use of irrigation versus no irrigation during burr hole evacuation of chronic subdural hematoma (CSDH). Methodology The study was a retrospective chart review of those patients who underwent burr hole evacuation of CSDH during a period of 5 years. Cases were divided into two groups based on the use of irrigation during surgery. A subdural drain was placed in all patients (i.e., in both the irrigation and no-irrigation groups) and removed 24 to 48 hours postoperatively. Results The total sample size was 56, of which 34 patients were in the irrigation group and 22 in the no-irrigation group. Recurrence rate was 17.6% in the irrigation group and 9.1% in the no-irrigation group (p = 0.46). Systemic complications were predominantly cardiac related in the no-irrigation group compared with respiratory complications in the irrigation group. The irrigation group had a mortality rate of 5.9% compared with 4.5% in the no-irrigation group (p = 0.66). Conclusion No statistically significant difference was found between the two groups in terms of recurrence or mortality.

Diagnostic Accuracy of Clinical Examination in Cervical Spine Injuries in Awake and Alert Blunt Trauma Patients

Study Design Observational, case series. Purpose To determine the sensitivity and specificity of clinical judgment as compared to the use of X-ray images in detecting cervical spine injuries in trauma patients presenting in the emergency department of Aga Khan University Hospital, Karachi. Overview of Literature Cross-table cervical spine views are important in patients with signs and symptoms relating to cervical spine, but asymptomatic patients constitute a different subgroup. Accuracy of clinical examination in these patients has not been subjected to scrutiny. Methods All patients with blunt trauma who presented to the emergency department and underwent cross-table X-rays as part of their trauma workup were included. The X-rays were read by a radiologist not aware of the history of the patients. We recorded demographic data along with mechanism of injury, associated neck signs or symptoms whether present or not, cervical spine range of motion, associated injuries and X-ray findings. The history and examination were carried out by the on-call neurosurgery team member. The sensitivity and specificity along with negative and positive predictive value of the clinical examination were calculated. Data were analyzed using SPSS ver. 16.0. Results Of 50 patients with positive signs and symptoms, 4 (8%) had positive X-rays while only 1 out of 324 (0.3%) with no associated signs and symptoms had positive X-ray findings. Conclusions The clinical examination is 80% sensitive and 73.98% specific in detecting true cervical spine injuries as compared to C-spine X-rays in alert and awake patients with blunt trauma.

Aneurysm in the anterior inferior cerebellar artery-posterior inferior cerebellar artery variant: Case report and review of literature

Highlights • We reported a case of an aneurysm in the AICA-PICA variant which was subsequently excised.• Considerable variation exists in the anatomy of the vertebrobasilar system.• Understanding the variations and the aneurysms that may arise from them is an important aspect of neurosurgical practice.

Development of Criteria Highly Suggestive of Spinal Tuberculosis

BACKGROUND In a developing country there is a need for development of criteria that can be used for the diagnosis of spinal tuberculosis, which is common in that region. METHODS Demographic, clinical, and radiologic features of spinal tuberculosis and spinal epidural tumors have been compared statistically, and inferences have been drawn in terms of P values, sensitivity, specificity, positive predictive values, and negative predictive values. RESULTS A statistically significant relationship was found between spinal tuberculosis and spinal pain, fever, gradually progressive lower limb weakness, contrast-enhancing epidural ± paravertebral lesions, continuous levels affected, spinal deformity, and raised erythrocyte sedimentation rate. CONCLUSIONS These relationships were considered the most probable criteria for the diagnosis of spinal tuberculosis.

Traumatic midline cerebellar contusion in 2-year-old male child—case report and review of literature

BackgroundCerebellar contusion accounts for 0.54% of traumatic brain injuries. They present with a variety of symptoms like ataxia, dysmetria, dysdiadokinesia, and vertigo. CT scan is the gold standard investigation for diagnosing acute cerebellar contusions. Due to the low incidence of this disease, there are no medical guidelines available for the management of cerebellar contusions.Case reportA 2-year-old child presented to the emergency department with altered level of consciousness. Computed tomography scan of the brain showed midline cerebellar contusion. He was managed conservatively with the main focus on lowering intracranial pressure.ResultCerebellar contusion can be managed conservatively with close monitoring. However, more data is needed to study its behaviour and management.ConclusionsThe patient had an excellent response to treatment and was discharged within a few days further highlighting the role of medical management in the treatment of patients with cerebellar contusions.

Spontaneous Intraventricular Hemorrhage: A Rare Presentation of a Skull Base Mesenchymal Chondrosarcoma

BACKGROUND Chondrosarcomas are very rare malignant, slow-growing tumors that develop in or near the petroclival region of the brain. We report a very rare case in which the tumor originated from left petrous bone and induced intraventricular hemorrhage leading to an acute comatose presentation. CASE DESCRIPTION A 28-year-old man initially presented to the outpatient department with a 1-month history of headache, vomiting, vertigo, and left facial numbness. A lesion at the cerebellopontine angle with extension into the middle cranial fossa was demonstrated on computed tomography and magnetic resonance imaging. The following night his condition worsened, and he presented to the emergency department with intraventricular hemorrhage with hydrocephalus. An external ventricular drain was placed in the emergency department to relieve hydrocephalus, and definitive surgical resection of the tumor was subsequently. Postoperatively, his Glasgow Coma Scale score improved, and he was transferred to the surgical intensive care unit where he remained for 3 days. He was subsequently stepped down to a special care unit and then to a ward room. The patient is currently awake and has grade II facial palsy (House-Brackmann), demonstrates spontaneous purposeful eye opening, inconsistently obeys single-step orders, demonstrates no meaningful phonation or vocalization, and has at least grade 4 power in all 4 extremities. He is currently fed through a nasogastric tube and is in rehabilitation. CONCLUSIONS Our experience of petroclival junction chondrosarcoma causing intraventricular hemorrhage may be the first to be documented. Preferred treatment of this highly malignant lesion is radical removal with postoperative radiotherapy.

Pilocytic astrocytoma: A rare presentation as intraventricular tumor

Background: Pilocytic astrocytoma (PA) is the most prevalent central nervous system (CNS) tumor in pediatric population and accounts for an approximate of 5–6% of all gliomas. This neoplasm can occur at all levels of the neuraxis, with majority (67%) arising in the cerebellum and optic pathway. PAs are World Health Organization Grade I tumors and are the most benign of all astrocytomas characterized by an excellent prognosis. Other differentials include subependymal giant cell astrocytoma (SEGA), ependymoma, meningioma, and low-grade gliomas such as pilocytic or diffuse astrocytoma; calcification is more commonly regarded as a feature of benign or slow-growing tumors. Case Description: We present a case of a 17-year-old female presenting with an unusual cause of hydrocephalus, a rare case of a calcified pilocytic astrocytoma as an intraventricular tumor. Conclusion: PA rarely presents as an intraventricular tumor and should be included in the differential diagnosis of a large mass with massive intratumoral calcification.