Harnarayan Singh

Serum lipid profile spectrum and delayed cerebral ischemia following subarachnoid hemorrhage: Is there a relation?

Background: Serum lipid abnormalities are known to be important risk factors for vascular disorders. However, their role in delayed cerebral ischemia (DCI), the major cause of morbidity after subarachnoid hemorrhage (SAH) remains unclear. This study was an attempt to evaluate the spectrum of lipid profile changes in SAH compared to matched controls, and their relation with the occurrence of DCI. Methods: Admission serum lipid profile levels were measured in patients of SAH and prospectively studied in relation to various factors and clinical development of DCI. Results: Serum triglyceride (TG) levels were significantly lower among SAH patients compared to matched controls (mean [±standard deviation (SD)] mg/dL: 117.3 [±50.4] vs. 172.8 [±89.1], P = 0.002), probably because of energy consumption due to hypermetabolic response. Patients who developed DCI had significantly higher TG levels compared to those who did not develop DCI (mean [±SD] mg/dL: 142.1 [±56] vs. 111.9 [±54], P = 0.05). DCI was noted in 62% of patients with TG >150 mg/dL, compared to 22% among the rest (P = 0.01). Total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol and lipoprotein (a) neither showed a significant difference between SAH and controls and nor any significant association with DCI. Multivariate analysis using binary logistic regression adjusting for the effects of age, sex, systemic disease, World Federation of Neurosurgical Societies grade, Fisher grade, and clipping/coiling, revealed higher TG levels to have significant independent association with DCI (P = 0.01). Conclusions: Higher serum TG levels appear to be significantly associated with DCI while other lipid parameters did not show any significant association. This may be due to their association with remnant cholesterol or free fatty acid-induced lipid peroxidation.

Application of a Far-Lateral Approach to the Subaxial Spine: Application, Technical Difficulties, and Results

OBJECTIVE The far-lateral approach has traditionally been used as an approach to ventral foramen magnum pathologies. Ventral pathologies in the cervical spine and cervicodorsal regions also provide unique surgical challenges. Traditional posterior surgical approaches to the ventral cervical pathologies require significant cord retraction, and anterior approaches require significant bone removal with implant stabilization. We approached these lesions using a modification of the far-lateral approach for lesions in the subaxial spine. METHODS Four patients underwent operations using this approach for ventral intradural pathologies in the subaxial spine. Two of the patients had recurrence of the lesions and underwent previous operations using a traditional midline approach. RESULTS All 4 patients underwent operations using this approach. This provided a unique view of the ventral pathologies and a scarless field in recurrent cases. All 4 patients improved neurologically after the surgery and had no deterioration or complications related to the surgery. CONCLUSION We propose extension of far-lateral approach to ventral intradural extramedullary lesions in the subaxial spine up to the cervicothoracic junction. The far-lateral approach can be extended safely to the ventral and ventrolateral lesions of the subaxial cervical spine, especially for recurrent or residual lesions previously approached from the midline posteriorly.

Vasospasm following aneurysmal subarachnoid hemorrhage: Thrombocytopenia a marker

Background: Symptomatic vasospasm (SV) is often seen after aneurysmal subarachnoid hemorrhage (aSAH). The pathophysiology suggests that platelets initiate the process and are consumed. This is likely to result in thrombocytopenia. The objective of this study was to find out if thrombocytopenia preceded or followed SV and to analyze the relationship between the two. Materials and Methods: The platelet counts of 74 patients were studied on day 1, 3, 5, 7, 9, 11, and 14 following aSAH. Clinical symptoms and raised velocities on transcranial Doppler were studied on the same days to determine SV. The relationship of platelet counts and SV were analyzed. Results: Thirty-nine (52.7%) patients developed SV. Platelet counts dropped on postictal day (PID) 3-7 and SV was commonly seen on PID 5-9. The median platelet counts were significantly lower in patients with SV when compared to those without SV. Platelet count <150,000/mm3 on PID 1 and 7 had statistically significant association (P < 0.001) with SV. The odds ratio was 5.1, 6.9, and 5.1 on PID 5, 7, and 9, respectively, for patients with relative thrombocytopenia (P < 0.001). Conclusions: There is a strong correlation between thrombocytopenia and SV. A platelet count < 150,000/mm3 on PID 1 and 7 predicts presence of SV. The relative risk of developing SV is >5 times for a patient with relative thrombocytopenia especially on PID 5-9. Additionally, it appears that thrombocytopenia precedes vasospasm and may be an independent predictor. However, this requires further studies for validation.

Syringe Port: A Convenient, Safe, and Cost-Effective Tubular Retractor for Transportal Removal of Deep-Seated Lesions of the Brain

OBJECTIVE Minimally invasive transportal resection of deep intracranial lesions has become a widely accepted surgical technique. Many disposable, mountable port systems are available in the market for this purpose, like the ViewSite Brain Access System. The objective of this study was to find a cost-effective substitute for these systems. METHODS Deep-seated brain lesions were treated with a port system made from disposable syringes. The syringe port could be inserted through minicraniotomies placed and planned with navigation. All deep-seated lesions like ventricular tumours, colloid cysts, deep-seated gliomas, and basal ganglia hemorrhages were treated with this syringe port system and evaluated for safety, operative site hematomas, and blood loss. RESULTS 62 patients were operated on during the study period from January 2015 to July 2017, using this innovative syringe port system for deep-seated lesions of the brain. No operative site hematoma or contusions were seen along the port entry site and tract. CONCLUSIONS Syringe port is a cost-effective and safe alternative to the costly disposable brain port systems, especially for neurosurgical setups in developing countries for minimally invasive transportal resection of deep brain lesions.

Lateral ventricular gliosarcoma with attachment to septum pellucidum

Gliosarcomas are lesions with both glial and sarcomatous elements and are usually seen abutting the dura. Intraventricular location is extremely rare. Such an unusual intraventricular gliosarcoma is being reported.

Types of Azygos Distal Anterior Cerebral Artery Branching Patterns: Relevance in Aneurysmal Surgery.

Azygos distal anterior cerebral artery (Az.DACA) is a rare anatomical variant. This variant has been found to be associated with aneurysms in a significant proportion of patients. We present two cases of Az.DACA aneurysms associated with this anatomical variant with different branching patterns and the corresponding technical difficulties in clipping such aneurysms. Aneurysms associated with Az.DACA present unique technical challenges in proportion to the number of branches arising near the neck and should be managed at high volume centres with the best of facilities.

Marker-CT assisted surgery using household key ring: A simple substitute to frameless stereotaxy for developing countries

Background: Operative localization systems such as stereotactic frames and neuronavigation are prohibitively expensive to be of use in many centers in developing countries. Here, we present a modified version of marker-computed tomography (CT) assisted technique using a household key ring, which can be performed in any operative set-up lacking modern amenities. Case Description: For a patient who presents with left posterior frontal lesion, the approximate entry point for the shortest and perpendicular trajectory to the lesion is marked on the scalp using a household key ring and fixed in place. Helical CT is obtained and reconstruction performed in two planes perpendicular to the ring and mutually perpendicular to each other. Based on the measurements of the lesion in relation to the radiologic pointers of the ring, and the location of the corrected entry point with respect to the center of the ring, the shortest perpendicular depth of approach is determined. Freehand technique perpendicular to the surface at the predetermined entry point and depth is employed for the surgical approach. The advantages of key ring over other markers are its simplicity, conformity to the shape of the head, and paucity of artifacts in CT. Conclusion: The relatively effortless estimation and three-dimensional visual impression renders this method easy enough to be employed anywhere for the operative localization of superficial intracranial lesions both for biopsy as well as resection.