Kanwaljeet Garg

Role of simvastatin in prevention of vasospasm and improving functional outcome after aneurysmal sub-arachnoid hemorrhage: a prospective, randomized, double-blind, placebo-controlled pilot trial

Abstract Background. Vasospasm plays a major role in the morbidity and mortality after aneurysmal subarachnoid hemorrhage (aSAH). The preliminary studies suggest that statins protect against cerebral vasospasm. Objective. The aim of the study was to determine the role of simvastatin in preventing clinical vasospasm and improving functional outcome in patients with aSAH. Methods. All patients with aSAH admitted within 96 h of ictus were randomized to receive either Simvastatin or placebo – 80 mg/day for 14 days. Thirty eight patients were recruited in the study- 19 received Simvastatin and 19 placebo. All the patients underwent surgical clipping of the aneurysm. The primary outcome of the study was the development of clinical cerebral vasospasm. The secondary outcomes included Glasgow Outcome Score (GOS), Modified Rankin Scale (MRS) and Barthel Index Score (MBI) at follow-up at 1, 3 and 6 months. Results. 16% of the patients in the simvastatin group had high Middle Cerebral Artery velocities (> 160 cm/sec) on transcranial Doppler on one or more than one day during the study duration as compared to 26% of the patients in the placebo group (p = 0.70). Neurological deterioration occurred in 26% and 42% of the patients in simvastatin group versus placebo group, respectively (p = 0.31). There was an improvement in the functional outcome in the simvastatin group at 1, 3 or 6 months in the follow-up; however, this difference was not statistically significant. Conclusions. There was benefit of simvastatin in terms of reduction in clinical vasospasm, mortality or improved functional outcome, however, this was not statistically significant.

Transorbital penetrating cerebral injury caused by a wooden stick: surgical nuances for removal of a foreign body lodged in cavernous sinus.

PurposePenetrating head injury (PHI) is rare in civilian population and is mostly caused by low-velocity modes. A transorbital penetrating intracranial injury is very rare and more severe than traumatic brain injury.MethodsWe report a rare case of transorbital penetrating cranial injury caused by a wooden stick. The surgical strategy was planned as the wooden stick was lodged in the right cavernous sinus.ResultsThe wooden stick was successfully removed. Patient made an uneventful recovery.ConclusionsTransorbital penetrating injuries are uncommon form of injury and require a multidisciplinary approach. No attempt should be made to remove the foreign body without the backup of an operating room because of the possibility that the object may be tamponading an injured vessel. A careful planning and a strict adherence to basic perioperative principles can lead to a satisfactory outcome.

Computed Tomography-guided C2 Pedicle Screw Placement for Treatment of Unstable Hangman Fractures

Study Design. Case series and description of technique. Objective. The purpose of this study was to evaluate the feasibility and accuracy of inserting pedicle screws in unstable Hangman fracture cases by using intraoperative CT (O-arm) based navigation. Summary of Background Data. Hangman fracture, also known as traumatic spondylolisthesis of the C2, is defined as a fracture involving the lamina, articular facets, pedicles, or pars of the axis vertebra. Opinions vary regarding the optimal treatment of unstable Hangman fractures. Some authors have recommended the use of rigid orthosis, whereas others have recommended surgical stabilization. The peculiar anatomy of the upper cervical spine is highly variable, and the presence of surrounding neurovascular structures makes pedicle screw fixation even more technically challenging. The advent of intraoperative 3-dimensional navigation systems permits safe and accurate instrumentation of the cervical spine. Methods. Ten patients with unstable Hangman fracture, with age ranging from 17 years to 81 years, were operated under O-arm–based navigation, and screw position was confirmed with intraoperative computed tomographic scan. Results. A total of 52 screws were inserted under O-arm guidance: 20 in C2 pedicle, 20 in C3 lateral mass, and rest in C4 lateral mass. Screw misplacement was seen in only 1 C2 pedicle screw (1 of 20, 5%). No new-onset neurological deficit developed in any of the patients. Follow-up ranged from 3 months to 21 months. Bony fusion was achieved in all. Full rotation was preserved at C1–C2 joint. All the patients (50%) with neurological deficits before surgery improved after surgery. Conclusion. This series demonstrates that C2 pedicle screws can be put with precision under O-arm–guided navigation, and intraoperative computed tomographic scan can confirm position of screws. Patients can be operated and mobilized early with negligible risk of screw misplacement, with preservation of motion at the C1–C2 joint. Level of Evidence: 4

Management of adult tethered cord syndrome: Our experience and review of literature

BACKGROUND Tethered cord syndrome (TCS) is a complex clinicopathologic entity, mostly described in children with limited number of studies describing in adults. This unique and rare subgroup of patients presents with characteristic features of TCS, but unlike children, pain is a predominant clinical symptom. MATERIALS AND METHODS Case records of 24 patients aged ≥16 years who had undergone surgery with a diagnosis of TCS between 2001 and 2011 were reviewed. Patients who have underwent surgery earlier for tethered cord or for diastematomyelia/spinal dysraphism and patients who had radiological evidence of tethering elements like lipoma of the cord on magnetic resonance imaging (MRI) were excluded from the study. RESULTS Low backache was the most common presenting symptom. At the time of final follow-up, 15 (83.3%) patients had shown improvement in backache. Weakness improved by at least one grade in seven (77.8%) patients. Bladder symptoms improved in six (50%) patients. CONCLUSION In case of symptomatic patient with low-lying cord, detethering is an advisable option.

Microvascular decompression for hemifacial spasm: A systematic review of vascular pathology, long term treatment efficacy and safety

Introduction: Hemifacial spasm (HS) is a rare disorder caused by the compression of facial nerve root exit zone (REZ) at the brainstem by a vascular loop. Microvascular decompression (MVD) is a popular treatment modality for HS. Objective: The purpose of this study was to determine the long-term efficacy and safety of MVD for HS by assessing the effect of the procedure from the literature published over the last 25 years. Materials and Methods: A systematic data review from 1992 to 2015 using specific eligibility criteria yielded 27 studies on MVD for HS, the data of which were pooled and subjected to a meta-analysis. Results: The pooled odds ratio (OR) revealed by the meta-analysis showed that anterior inferior cerebellar artery was the most common offending vessel in 37.8% (95% confidence interval [CI]: 27.8–47.7%) of the patients. Complete resolution of HS was seen in 88.5% (95% CI: 86.7–90.4%) of the patients after a long-term follow up. The complication rate was low following MVD, the most common being temporary facial paresis in 5.9% (95% CI: 4.3–7.5%) of patients. Conclusions: MVD is a safe and effective treatment for HS with long-term benefits and a low complication rate.

Quadrigeminal cistern arachnoid cyst: A series of 18 patients and a review of literature

Abstract Background. Arachnoid cysts account for 1% of intracranial mass lesions. Quadrigeminal cistern arachnoid cysts are even rarer lesions. We report 18 cases of quadrigeminal cistern arachnoid cysts treated at our institute from 2002 to 2012. Methods. We retrospectively analysed 18 patients with quadrigeminal cistern arachnoid cyst for clinical presentation, demographic profile, management and outcome. The age of the patients ranged from 29 days to 50 years (mean 17 years). The cysts were classified into 3 subtypes based on MRI findings. Surgical intervention was carried out in all the patients. Results. Two patients had Type 1 cysts, 4 had Type 2 cysts and 12 had Type 3 cysts. Two patients (Type 1) underwent endoscopic third ventriculostomy (alone). Craniotomy and cyst wall excision along with ventriculocystostomy and cystocisternostomy were done in 4 patients with Type 2 cysts, and endoscopic fenestration of cysts to the sub-arachnoid space or the ventricles and endoscopic third ventriculostomy were done in 7 patients with Type 3 cysts. Two patients with Type 3 cysts underwent only endoscopic ventriculocystostomy and cystocisternostomy without endoscopic third ventriculostomy, while three patients underwent ventriculoperitoneal shunt. The follow- up period ranged from 6 months to 48 months (mean 23.7 ± 12.3 months). Conclusion. Quadrigeminal plate arachnoid cysts are generally symptomatic and require some form of surgical intervention. We believe that endoscopic fenestration of the cyst with cystocisternostomy or cystoventriculostomy, when combined with third ventriculostomy, is the procedure of choice for such patients. We do not recommend the placement of a ventriculoperitnoeal shunt alone. Operative re-exploration should be planned only after obtaining proper clinico-radiological correlation and not on the basis of imaging findings alone, as sometimes the cysts fail to regress but the symptoms improve.

Remote site intracranial hemorrhage: Our experience and review of literature

Sudden decompression in a patient with chronically raised intracranial pressure (ICP) can very rarely lead to bleeding away from the operative site. In this retrospective review the intention is to highlight the possible causes of remote bleed. Data of six patients with remote site bleed in the postoperative period operated at our center were retrospectively reviewed. Medline and Pubmed databases were searched for similar cases and were reviewed systematically to understand the cause, management, and outcome. In our series the mean age of patients was 35.5 years. Three patients each were operated for supratentorial and infratentorial pathologies. Of the six patients, three patients were operated for tumors. Of the 89 patients with remote site bleed in the postoperative period,64 (72%) patients had supratentorial tentorial and in the remaining it was infratentorial surgery. Most common site of bleed was supratentorial in 72 {81 %) patients. The reported mortality was 28% (21 patients). Remote site intracranial bleed following cranial surgery is a rare but well-documented complication. It can prove fatal and may cause significant morbidity. We advocate keeping high index of suspicion and ear[y computed tomography(CT) scan head in postoperative period.

Isolated central canal rupture of spinal dermoid. Report of 3 cases.

Spinal dermoid tumors are rare, benign, slow-growing tumors. Rupture of spinal dermoids, in contrast to cranial dermoids, is rarely reported. Rupture in the central canal alone is even more rare, with only a few cases reported in the literature. The presence of fat droplets within the central canal is unusual because the central canal is rudimentary in adults. The authors report 3 such cases and review the pertinent literature.

Bilateral abducens nerve palsy associated with subarachnoid hemorrhage.

Abstract Objective. Isolated abducens nerve palsies associated with intracranial aneurysms have rarely been reported. The purpose of the study was to study the patients with bilateral abducens nerve palsy in association with subarachnoid hemorrhage (SAH). Methods. All patients admitted and managed at our center with a diagnosis of SAH and had bilateral abducens nerve palsy were included in the study. The demographic and clinical details, radiological findings, treatment data, and outcome of these patients were retrieved from the computerized database of our hospital. Results. Nine patients, with a mean age of 49.4 years, met the inclusion criteria. Male to female ratio of 1.25:1). Average duration of symptoms before presentation was 2.6 days (ranging from 1 to 4 days). Third nerve palsy in addition to bilateral abducens nerve palsy was present in 4 patients (44%). DSA demonstrated aneurysms in 7 patients; 4 had posterior circulation aneurysms and 3 had aneurysms of anterior circulation. Two patients had angionegative SAH. The abnormality resolved in all but one patient over a time period of 4–9 weeks, and one patient died due to unrelated cause. Conclusions. Bilateral abducens nerve palsy in association with SAH is rarely described. Proposed mechanisms include direct compression of the bilateral abducens nerves, vasospasm of the pontine branches of the basilar artery and hydrocephalous. Most of the patients in our series showed resolution of the symptoms over a period of 4–9 weeks.

Long segment spinal epidural extramedullary hematopoiesis.

Background: Extramedullary hematopoiesis is defined as the formation of blood cells outside the bone marrow. It is a common manifestation of many chronic hemolytic anemias, and typically involves the liver, spleen, and lymph nodes. Only rarely is the spinal epidural space involved. Methods: We describe a 25-year-old male, known to have thalassemia intermedia, who presented with a 1-month history of stiffness and weakness in both lower extremities. On physical examination, he had palpable splenomegaly accompanied by spinal tenderness at the D5 level, weakness in both lower extremities, hyperactive bilateral Patellar and Achilles reflexes with bilateral Babinski responses, and a graded sensory loss to pin appreciation below D5. Results: The magnetic resonance (MR) study revealed a posterior, isointense and soft tissue epidural mass extending from D2 to D12 on both the T1- and T2-weighted images. These findings were consistent with the diagnosis of “red marrow,” and long-segment spinal epidural extramedullary hematopoiesis. Conclusions: Although extramedullary hematopoiesis is rarely encountered within the spinal canal, it should be considered among the differential diagnoses when a posterior compressive thoracic lesion contributes to myelopathy in a patient with a history of thalassemia intermedia and the accompanying chronic hemolytic anemia.