Hitesh Gurjar

Decompressive craniectomy in traumatic brain injury: A single-center, multivariate analysis of 1,236 patients at a tertiary care hospital in India

OBJECT To evaluate the outcome of patients undergoing a decompressive craniectomy (DC) in traumatic brain injury (TBI) and the factors predicting outcome. MATERIALS AND METHODS A total of 1,236 patients with TBI operated with a DC from January 2008 to December 2013 at a tertiary care hospital were included in the study. The data from the hospital computerized database was retrospectively analyzed and 324 (45%) patients were followed-up for a mean duration of 25.3 months (range 3-42 months) among the cohort of 720 alive patients. The institutes ethical committee clearance was obtained before the start of the study. RESULTS There were 81% males with a median age [interquartile range (IQR)] of 32 (23-45) years. The mortality rate and median (IQR) Glasgow outcome score (GOS) at discharge in patients presenting with minor, moderate, and severe head injury were 18%, 5 (4-5); 28%, 4 (1-5); and 47.4%, 2 (1-4), respectively. An overall favorable outcome (GOS 4 and 5) at discharge was observed in 46.5% patients and in 39% patients who presented with severe TBI. Only 7.5% patients were in a persistent vegetative state (PVS), while 78% had an overall favorable outcome at the last follow-up of surviving patients (P < 0.001). On multivariate analysis, the factors predictive of a favorable GOS at discharge were: a younger age (odds ratio (OR) 1.03, confidence interval (CI) = 1.02-1.04; P < 0.001), no pupillary abnormalities at admission (OR 2.28, CI = 1.72-3.02; P < 0.001), absence of preoperative hypotension (OR 1.91, CI = 1.08-3.38; P = 0.02), an isolated TBI (OR 1.42, CI = 1.08-1.86; P = 0.01), absence of a preoperative infarct (OR 3.68, CI = 1.74-7.81; P = 0.001), presence of a minor head injury (OR 6.33, CI = 4.07-9.86; P < 0.001), performing a duraplasty (OR 1.86, CI = 1.20-2.87; P = 0.005) rather than a slit durotomy (OR 3.95, CI = 1.67-9.35; P = 0.002), and, avoidance of a contralateral DC (OR 3.58, CI = 1.90-6.73; P < 0.001). CONCLUSIONS The severity of head injury, performing a duraplasty rather than a slit durotomy, avoidance of a contralateral DC, and the presence of preoperative hypotension, infarct, and/or pupillary asymmetry have the highest odds of predicting the short term GOS at the time of discharge, after a DC in patients with TBI. Although DC carries a high risk of mortality, the probability of the survivors having a favorable outcome is significantly more as compared to those who remain in a PVS.

Surgical management of giant multilevel aneurysmal bone cyst of cervical spine in a 10-year-old boy: case report with review of literature.

Background: Aneurysmal bone cysts are rare occurrences in the cervical spine. Surgical treatment in pediatric patients is a challenge. Complete tumor resection offers the best chance for cure. Description: Diagnosis and surgical management of an expansile aneurysmal bone cyst of the cervical spine involving all three spinal columns in a 10-year-old boy. Results: Surgical treatment included tumor excision and circumferential fusion, and produced no neurological or vascular sequelae. This approach minimizes the risk of recurrence and the possibility of postoperative spinal instability. Conclusion: Spinal instability is preferably addressed with reconstruction and stabilization. Cervical aneurismal bone cyst lesions are ideally treated with complete resection to minimize the chance of recurrence. In pediatric cases, defects created by resection should be corrected by fusion to minimize the risk of postoperative instability and growth abnormality.

Third ventricular tuberculoma

There are many important implications of a heavily calcifi ed intraventricular PA. First, it indicates a slow growing benign lesion which calcifi ed over a period of time. Since these lesions produce symptoms because of obstruction of cerebrospinal fl uid, they take a long time for to be symptomatic. Second, it makes the surgery challenging, as it is diffi cult to remove such large calcifi ed tumor in one piece owing to its large size, which may cause surrounding brain injury. In our both cases, the calcifi ed mass was very hard, could not be sucked with ultrasonic surgical aspirator or cut with a knife. The tumor had to be broken and was delivered out piecemeal using Kerrison punches and fi ne bone nibblers. In both cases, there was a pedicle with multiple vessels at the base, which could be seen only after most of the calcifi ed mass was removed. The most diffi cult part of the surgery was to break it into smaller pieces without causing injury to surrounding parenchyma and without disrupting the pedicle with vessels. However, with careful dissection with patience, complete excision and excellent outcome can be achieved.

Multicentric intracranial epidermoid or epi/dermoid cysts?

Sir, Epidermoid cysts account for 0.2 to 1.8 % of all intracranial tumors. They generally occur in the cerebellopontine angle (CPA) or in the parasellar cisterns [1]. Intracranial multicentric epidermoid cysts are an extremely rare occurrence [3]. A 40-year old male, operated on elsewhere for a right CPA epidermoid cyst 12 years previously, presented with gradually progressive voice hoarseness, dysphagia and ataxia for the last 6 months. On examination, the patient had moderate sensorineural hearing loss, an impaired gag reflex and cerebellar signs on the right side. Radiology revealed two mass lesions—one centered in the right ambient cistern extending into the prepontine, interpeduncular and CPA cisterns, and the other in the corpus callosal cistern. On computed tomography, the ambient cisternal mass was hypodense, while the pericallosal one showed calcification (Fig. 1a-c). Both the lesions were hypointense on T1-weighted MR images (Fig. 1d,e) and hyperintense on T2-weighted MR images, with no intercommunication through either the ventricles or the quadrigeminal cisterns(Fig. 1f). A diagnosis of a multicentric epidermoid cyst was considered. The simultaneous occurrence of epidermoid cysts may be secondary to ‘tumor burst’ [3]. A single epidermoid cyst in the ambient cistern may have ruptured because of increased intracystic pressure resulting in the dissemination of tumor cells to the pericallosal cistern. However, there are no radiological markers to suggest that such an eruption occurred. Perhaps, this multicentricity occurred during the process of ectodermal neurocutaneous separation between the 3rd–5th weeks of embryonic life [2]. Separate heterotopic epithelial rests may have formed with no contiguity. The ambient cisternal lesion may have resulted from ectodermal inclusions during the formation of the secondary otic vesicle, whereas the midline pericallosal cisternal mass may have been caused during the primary separation of the neuroectoderm from its cutaneous counterpart in the dorsal midline [2]. Calcification in epidermoid cysts is extremely rare and is thought to occur secondary to dystrophic change in the rim [4]. The midline cyst in this patient, which demonstrated chunky intralesional calcification, was therefore radiologically and embryologically, in all probability, a dermoid. Ectodermal separational failure may have occurred at two distinct points during embryogenesis with the dermoid cyst predating the epidermoid. N. Goyal :M. S. Sharma (*) :H. Gurjar :A. K. Mahapatra Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi 110029, India e-mail: manishsinghsharma@gmail.com

Massive life-threatening bifrontal epidural hematoma following placement of an external ventricular drain.

Dear Editor: External ventricular drainage is a life-saving neurosurgical procedure for CSF drainage in acute hydrocephalus. External ventricular drain (EVD) was first described by Dandy [2]. Most common EVD-related complications include infection and hemorrhage; however, literature on hemorrhagic complications of EVD remains sparse [4, 5]. Epidural hematoma is a rare complication and can occur at site of placement or at a distant site due to sudden decompression and dural stripping from the overlying bone. A 17-year-old male patient, a diagnosed case of thalamic glioma who received primary radiotherapy, presented to us with complaints of headache, repeated vomiting, and drowsiness. On examination, his GCS was E1VtM2. Non-contrast CT (NCCT) scan of the head showed right thalamic tumor with hydrocephalus (Fig. 1a). An EVD was inserted through right frontal twist drill craniostomy, at the Kocher’s point. CSF was under high pressure, and the EVD bag was kept at a level of patient’s tragus. The patient became conscious (GCS E4VtM6) after the placement of the EVD. After 4 h of EVD placement , pat ient again became unresponsive (GCS E1VtM1), and the EVD had drained 50 ml of CSF by then. NCCT scan of the head revealed massive bifrontal epidural hematoma (EDH) and the EVD tip was in the frontal horn of the right lateral ventricle (Fig. 1b). A bicoronal scalp incision, bilateral frontal bone flap was elevated and EDH was evacuated. The superior sagittal sinus and the bifrontal dura were found stripped from the bone. Multiple central and peripheral dural hitches were applied and the bone flap was placed back. The patient regained consciousness after surgery and his sensorium improved following surgery to E4VtM6 with CT head showing complete evacuation of EDH (Fig. 1c). Eight hours after EDH evacuation, the patient again became E1VtM1. NCCT scan showed dilatation of ventricles, so a right parietal EVD was inserted. The patient again regained consciousness (GCS E4VtM6). The EVD was converted to a ventriculo-peritoneal shunt as a definitive measure of CSF diversion after 48 h (Fig. 2a, b). The patient was doing good at 3 months follow-up with a functioning shunt. External ventricular drainage is one of the life-saving procedures in neurosurgery, although tapping ventricle still can cause hemorrhagic complications due to injury to cortical vein or the subependymal vasculature. The reported hemorrhagic complications of an EVD include a parenchymal bleed, intraventricular bleed, and subdural or epidural hematomas [1, 3]. Intra-parenchymal and subdural hematomas are mostly due to direct trauma, whereas an EDH occurs as a result of direct trauma to the dural vessel, venous lacunae, and diploe or may be due to the sudden decompression of the ventricles, * Kanwaljeet Garg gargneuro@hotmail.com

Armored brain-massive bilateral calcified chronic subdural hematoma in a patient with ventriculoperotoneal shunt.

Khoshyomn 2002 M, 73 Multiple nodules of lateral, third, fourth ventricles Headache, nausea, vomiting Right shoulder with negative axillary node 36 No Neuroendoscopic biopsy of lateral ventricle lesions, radiotherapy, chemotherapy (methotrexate, cytosine arabinoside) Cipri 2009 M, 22 Septum pellucidum Intermittent headache, vomiting, disequilibrium Unknown Left inguinal, bilateral suprarenal, left bronchopulmonary parailar Neuroendoscopic biopsy, pellucidostomy, VP‐shunt, stereotactic radiosurgery, chemotherapy (TMZ, thalidomide) for systemic locations Present case F, 60 Left lateral ventricle Headache, vomiting, confusion Left knee 10 No Surgery, chemotherapy, radiotherapy 8 months, no recurrence

Large pontine tubercular abscess treated surgically

Abstract Tuberculosis of the central nervous system (CNS) is a life threatening condition with 50% mortality in advanced disease and serious neurological deficits in those who survive. Tuberculous abscess is a rare manifestation of CNS tuberculosis, brainstem involvement being even rarer. The management of these conditions poses a great challenge to the treating physician. We report a case of large tubercular abscess of pons which increased in size on anti-tubercular treatment, but showed excellent improvement following craniotomy and aspiration.

Management of Choroid plexus tumors in infants and young children up to 4 years of age: An institutional experience

BACKGROUND Choroid plexus tumors (CPTs) are rare tumors characterized by papillary and intraventricular growth. The young age of presentation of such tumors, especially in infants, and the lack of consensus on adjuvant therapy in case of atypical choroid plexus papilloma (aCPP) and choroid plexus carcinoma (CPC) create dilemma for the management of such tumors. We discuss the presentation, management, complications, and outcome in 15 patients (children 4 years of age and younger) and review pertinent literature. METHODS We retrospectively analyzed the case records of all patients with CPTs who were operated in our institute from January 2010 to March 2018. We found 15 patients in the age group of 0-4 years of age. The variables analyzed include age, sex, presentation, location, surgical approach, extent of resection, intraoperative blood loss, percentage of blood loss, blood transfused, histopathology, postoperative complications, and outcome. Images were obtained from picture archiving and communication system, and patient details and follow-up were obtained from discharge summary, operative notes, and hospital records. RESULTS Ten patients had choroid plexus papilloma (CPP), 2 patients had aCPP, and 3 patients had CPC. The mean age was 15.2 months, whereas the median age was 8 months (range, 40 days-4 years). The mean blood loss was 329 mL, whereas the median blood loss was 175 mL. There were a total of 5 deaths, including 3 patients with CPC and 1 each with aCPP and CPP. CONCLUSIONS CPTs are challenging tumors in infants and very young children because of the potential for massive blood loss. CPP is associated with lesser blood loss and favorable outcome compared with aCPP and CPC. Massive blood loss in CPC and aCPP can be life threatening as has been shown in our series. CPC has a rapid proliferation potential as shown in one of our cases. Attempts at decreasing vascularization of such tumors should be made by various methods, including preoperative embolization and neoadjuvant chemotherapy; however, a consensus on this is lacking.

Can diabetic ketoacidosis (DKA) precipitate posterior reversible encephalopathy syndrome (PRES)

Dear Editor: We read with keen interest the case report by Nao et al. [1] describing posterior reversible encephalopathy syndromewith spinal cord involvement (PRES-SCI) occurring as a complication of diabetic ketoacidosis. We would like to commend the authors for reporting a rare case of PRES-SCI in a patient with diabetic ketoacidosis (DKA). On reviewing the literature, we came across two similar case reports [2, 3] in which PRES occurred as a complication of DKA as discussed in Table 1. However, we would like to discuss a few issues in this report. The authors have reported that the patient developed numbness with paraplegia on day 5 along with headache and blurring of vision after resolution of DKA on day 4. The findings in magnetic resonance imaging (MRI) of brain and spinal cord were supportive of PRES-SCI. De Havenon et al. [4] in their series of eight patients reported that all patients had acute hypertension at the time of onset of neurological deficits, so it would have been interesting if authors had mentioned whether there was any evidence of systolic or diastolic hypertension at the time of visual deterioration and what were the fundus findings. Also, the authors did not describe the metabolic parameters of the patient in the ICU after neurological worsening as dyselectrolytemia may also interfere with cerebrovascular auto-regulation. Hypomagnesaemia has been reported to cause transient neurological symptoms associated with reversible T2 signal changes on MRI of PRES [5]. The authors should also have mentioned if there was any evidence of anemia or azotemia. Diabetic uremic syndrome has been shown to result in bilateral reversible lesions in the brain [6]. The authors have reported lower motor neuron features in their patient. However, this is in contrast to the previously reported cases of PRES in which the patients had upper motor neuron features with hyperreflexia and hypertonia [4]. Though the authors acknowledge that they could not rule out the possibility of myelitis and consequently started the patient on methylprednisolone, the rationale for this treatment is unjustified as it could further worsen glycemic control in a patient with history of DKA. Though the steroids might have helped in resolution of vasogenic edema in this case, however, most of the authors have reported gradual and complete resolution of the symptoms with adequate control of blood pressure and consider hyper-perfusion injury to be the main pathophysiological mechanism underlying PRES-SCI. * Hitesh Gurjar hiteshgurjar@gmail.com

Early tracheostomy in traumatic brain injury: conundrum continues…

We note with interest the article by Shibahashi et al. regarding the effect of tracheostomy performed within 72 hours following traumatic brain injury. We commend the authors for bringing this question in light, as there is no consensus regarding the optimal timing of doing tracheostomy after traumatic brain injury (TBI). Given the advantages of tracheostomy over endotracheal intubation, Plummer et al. recommended that tracheostomy should be performed if an artificial airway is anticipated for greater than 21 days. But in the current scenario, the decision regarding the timing of tracheostomy was left to the physician. Recent studies have advocated early tracheostomy after TBI because of advantages like decreased duration of mechanical ventilation and length of stay (LOS) in the intensive care unit (ICU). Unfortunately, the definition of early and late tracheostomy differs among studies with the earliest tracheostomy day chosen as early as 5th/6th day after injury in previous studies for group division. The authors in this study used the 72-hour cut-off for dividing into early and late groups. However, we would like to highlight issues in this article that need further consideration. The authors did not mention whether patients with baseline pulmonary diseases such as asthma, interstitial lung or COPD were excluded from the study as these could have confounded the results including the time taken for weaning off, LOS in ICU and associated morbidity and mortality. They have mentioned that tracheostomy was performed by the standardized technique using a low-pressure cuffed tracheostomy tube, but it is unclear whether it was done under GA or by percutaneous technique under local anesthesia. This could have a differential impact on the peri-procedural inflammatory markers that they have evaluated. The authors have not commented upon any contraindications for performing tracheostomy such as coagulopathy, which is quite common in the peri-traumatic period that could have resulted in a decision for delayed tracheostomy. The authors excluded 2 patients because of upper airway obstruction that required urgent tracheostomy but whether patients with maxillofacial trauma were excluded is unclear. The authors say that patients in the early group (n1⁄4 40) were expected to have a worse prognosis in terms of probability of survival, risk of mortality at 14 days and unfavorable outcome than those in the late group (n1⁄4 51) according to various prognostic models (CRASH and TRISS). However, the results seem quite surprising as the median total duration of mechanical ventilation [early group-5 (4–6); late group-8 (6–10)] and median LOS in ICU [early group-10 (7–13); late group-11 (10–15)] were significantly less in the early group. Also the time from tracheostomy to ventilator weaning was the same [2 (1–4) days] in both the groups. This median figure and the inter-quartile range are quite overwhelming considering the early subgroup had predicted mortality of more than 50% within the next 14 days. Even in the randomized controlled study by Bouderka et al, which used 5th/6th day as cut-off for deciding early versus late group, the duration of mechanical ventilation was never less than 14 days in the early tracheostomy group. Though the authors have acknowledged that these prognostic models took into account only the initial injury and effects of secondary injury were not considered, it might have been possible that patients with lower degrees of secondary brain were selected for the early tracheostomy group that resulted in early group fairing well; however, it is surprising that most of the patients were weaned off the ventilator within 2 days after being tracheostomised. Similar contradictory figures compared to initial prediction were also seen in the 30-day mortality with only one patient death in the early group, and the favorable GOS at time of discharge was similar i.e. 40% in both the groups. In addition, the decision to perform tracheostomy was on the basis of surgeon’s anticipation that the patient was going to need an artificial airway for more than 7 days; this introduces a selection bias in deciding between early and late groups. Moreover, the delay to perform tracheostomy because of family decision-making was not included in the study, which is a very common factor we see in ICU settings. The authors did not consider other independent factors, which may have played a role in patients’ outcomes such as APACHE and Simplified Acute Physiology Score (SAPE). In conclusion, we would like to commend the authors for the study highlighting the benefits of early tracheostomy but what is needed is a prospective study using standardized guidelines as to when to perform tracheostomy, removal of surgeons’ subjective bias and objectify it using a standardized scoring system. Otherwise, the debate for any specific time cut-off would remain unresolved.