Ishu Bishnoi

Assessment of surgical risk factors in the development of ventilator-associated pneumonia in neurosurgical intensive care unit patients: Alarming observations

Background: Ventilator-associated pneumonia (VAP) is the most frequent nosocomial infection in patients receiving mechanical ventilation (MV) and contributes to a longer intensive care unit (ICU) stay, duration of MV, and a high morbidity and mortality. Objective: The purpose of study was to determine the incidence of VAP in neurosurgery ICU patients and to assess the probable contributing neurosurgical risk factors like the site and nature of the lesion in the brain, the duration of surgery, blood loss during surgery, and infection elsewhere in the body, in the development of VAP. Materials and Methods: The prospective clinical study included patients with a Glasgow Coma Scale (GCS) score>8 undergoing a neurosurgical procedure and postoperatively receiving MV for >48 hours, who were followed for the development of VAP. The diagnosis of VAP was in accordance with the Centers for Disease control (CDC) guidelines and was confirmed with a positive quantitative culture in the endotracheal tube aspirate samples. Results: The incidence of VAP in our study was 70%. Aneurysmal subarachnoid hemorrhage (SAH) [Grade 3, 4 and 5] was the most common underlying condition followed by posterior fossa surgery, and surgery of the craniovertebral junction and cervical spine. Patients with a supratentorial compartment etiology had a slightly higher incidence (53%) of VAP as compared to the infratentorial compartment one. Patients with significant intraoperative blood loss and receiving blood transfusion had a higher incidence of pulmonary complications. Acinetobacter baumannii was the most common pathogen isolated followed by Pseudomonas aeruginosa, with high resistance trends being prevalent among the commonly used antibiotics in the ICU. Conclusion: The incidence of VAP is high. Patients of aneurysmal SAH are at higher risk and VAP is as common in patients with supratentorial lesions as in those with infratentorial pathologies. The increase in resistance to the commonly used antibiotics is a cause for concern. Efforts should be taken to evolve more effective preventive measures.

A Worst-Case Scenario—Undiagnosed Ruptured Arteriovenous Malformation Managed with Limited Resources

BACKGROUND Treatment of arteriovenous malformations (AVMs) is currently performed at specialized neurosurgical centers well equipped with microscopes with green filters, neurosurgical catheterization laboratories, and experienced neurosurgical teams. Patients in whom AVMs are diagnosed at smaller hospitals should be referred to such specialized centers. This case report describes the unavoidable worst-case scenario of an emergency unplanned surgical excision of an undiagnosed ruptured AVM with large hematoma. CASE DESCRIPTION A 26-year-old man was brought to the emergency department with episodes of seizures and sudden loss of consciousness. His Glasgow Coma Scale score was 5. He had anisocoria. Computed tomography of the head showed right occipital hematoma with mass effect and herniation. Suspected diagnosis was spontaneous tumor or hypertensive bleed. Emergency surgery was performed. Intraoperatively, ruptured AVM was found. After explaining to family members about nonavailability of conventional instruments (i.e., microscope, clips, indocyanine green), we planned for excision of AVM with available resources. CONCLUSIONS Postoperatively the patient recovered satisfactorily with right-side vision loss. He underwent cranioplasty after 6 weeks. In such a worst-case scenario, remaining calm, following basic surgical steps, using blood transfusion, and employing lateral thinking regarding using available resources can result in satisfactory management of the patient.

Real-time patency verification during clipping aneurysm and STA-MCA by-pass with dual-image videoangiography

Abstract The dual-image videoangiography (DIVA) is a new tool which helps identify vessels and surrounding structure. This method is based on use of indocyanine green video angiography (ICG-VA) technology on real time microscopic operative image. In this two case, we report of using DIVA in STA-MCA bypass surgery of 46 years old, female patient of stenosis of right MCA. And using DIVA during clipping ICA paraclinod aneurysm of 35 years old, female. During surgery, it helped in identifying temporal and frontal branches of the STA and there careful selection. After anastomosis, DIVA was used to refine vessel patency and functioning of the anastomosis. DIVA has the potential to replace ICG-VA as a tool for checking the patency of graft during bypass procedures and obliteration of aneurysm along with surgical procedures for AVM and d-AVF. DIVA allows visualization of vessels against a background of normal brain and has better visualization at greater depth and high magnification. This is particularly important during bypass surgery, which very often is performed in deep surgical fields and high magnification.

Intraventricular Tuberculoma in a Child: A Rare Location

Intracranial tuberculoma is an uncommon presentation of tuberculosis, and its occurrence in an intraventricular location is very rare. It is usually confused with glioma, parasitic cyst, and craniopharyngioma. Few case reports exist in the literature on this entity. We report a case of tuberculoma at the foramen of Monro in a 7-year-old child and review the literature in terms of diagnostic dilemma.

Occipital intraparenchymal myxopapillary ependymoma: Case report and literature review

Myxopapillary ependymoma (MPE) is a histological variant of ependymoma found in the conus medullaris or filum terminale region. Intracranial occurrence of the tumor is a rarity. The most characteristic histological feature of myxopapillary tumors is the abundance of intercellular and perivascular mucin and the arborizing vasculature, which tends to form papillae. We are reporting a 14-year-old patient presented with seizures caused by the right occipital region intraparenchymal lesion. Histopathology confirmed it to be MPE. Lesion was excised completely. Literature reviews on the topic are discussed regarding the histological findings, natural history, and outcome of surgically treated MPE. This is the fifth reported case of cerebral intraparenchymal primary MPE.

Redo microvascular decompression in a patient of resistant cochleovestibular nerve compression syndrome

Cochlea-vestibular nerve compression syndrome (CVCS) may present as recurrent attacks of vertigo, dizziness, imbalance, etc. Those patients who do not respond to medical management, are usually managed by “microvascular decompression (MVD) of cochlea-vestibular nerve.” The success rate of MVD is not 100% and few patients present with the recurrence of symptoms. We are reporting management of one such resistant case of CVCS. A 40-year-old female patient who was a known case of CVCS, was managed by medical and surgical (MVD) management. She had no relief of symptoms. We did redo MVD of cochlea-vestibular nerve after full evaluation of symptomatology. Patient had complete relief in her symptoms. In failed MVD cases, redo MVD can be performed if patient is still having e/o nerve compression, adhesions on magnetic resonance imaging.

Understanding the Course of Vertebral Artery at Craniovertebral Junction in Occipital Assimilation of Atlas: Made Simplified Using Conventional Angiography

Introduction Preoperative assessment of vertebral artery (VA) is important to avoid its injury during surgery at craniovertebral junction (CVJ). The main concern is the course of third segment of VA (V3) while performing instrumentation at CVJ, that is, segment of VA from its course through transverse foramen of C2 to its course along the posterior arch of C1. This segment of VA includes its passage through C1 transverse foramen as well. This observational study was done to analyze the course, curvature, and termination of VA in patients with occipital assimilation of atlas at CVJ, a complex congenital anomaly, and compared with the normal course for better understanding especially by young neurosurgeons and spine surgeons. Materials and Method This is an observational study that included patients with occipitalized C1 with or without associated anomalies. Out of 30 patients of CVJ anomalies, 16 patients had occipitalized atlas. Digital subtraction angiography was done in all cases. It was done by selectively catheterizing the VA using standard Seldingers technique and both anteroposterior and lateral projections were taken. Results The course of VA was not identical on either side in any individual. It was lengthened and tortuous in all patients. Different types of anomalous course were encountered like bypassing transverse foramen of C1, close relation with C1‐2 facet joints, variable course along the posterior arch of C1, abnormal termination and fenestration of VA. Conclusion Craniovertebral junction anomalies are not only bony or neural, but are vascular too. Complex CVJ anomalies are associated with higher incidence of anomalous course of the VA, an important surgical consideration.

An Alternate Vista in Rehabilitation of Cranial Defects: Combining Digital and Manual Techniques to Fabricate a Hybrid Cranioplast.

The desired features of a cranioplast include providing an acceptable contour, continuity with the remaining skull (marginal adaptation), improvising the aesthetic outcome, providing a strengthened prosthesis to avoid fracture in case of repeat trauma, and protecting the remaining neurological structures. Combining digital and manual techniques to fabricate a hybrid polymethylmethacrylate cranioplast during the rehabilitation of a pediatric patient with cranial defect has been described. Utilization of digital techniques (rapid prototyping to obtain skull analog) and manual (hand) sculpting of the prosthesis strengthened with glass fiber enabled the authors to fabricate a hybrid cranioplast. Satisfactory outcome was achieved.