M. A. Wani

Protrusion of a peritoneal catheter through the umblicus: an unusual complication of a ventriculoperitoneal shunt

Abstract Protrusion of a ventriculoperitoneal (VP) shunt through the umblicus is one of the rarecomplications of shunt insertion reported in the medical literature. One such case is presented here in a child in whom a VP shunt had been placed for congenital hydrocephalus.

Head Injury Caused by Tear Gas Cartridge in Teenage Population

Objectives: The aim of this study was to assess the head injury in children caused by an unusual projectile, a tear gas cartridge. The study is the only one on this subject which has been done in a teenage population. Method: This was a prospective study conducted over a period of 4 years in which all the patients aged less than or equal to 18 years and who had a head injury due to a tear gas cartridge were included. Results: We had 5 patients in our study group. All the patients were males. Commonest CT scan finding was brain contusion with skull fracture. One of our patients died. One patient continues to be in vegetative state whereas 3 had a good outcome. Conclusion: Tear gas cartridge, though considered as one of the benign modalities of controlling agitated crowds, is not really benign. It can cause serious injuries and mortality. The personnel using them might be trained in a better way so that the people do not receive direct hits. In addition some changes in the design of tear gas cartridge can be done to decrease the impact to the skull.

Decompressive craniectomy in head injury

Decompressive craniectomy has been used to treat severe intracranial hypertension secondary to various causes like trauma, cerebral infarction, subarachnoid hemorrhage, and spontaneous hemorrhage, refractory to medical treatment. There are many different approaches grouped under the term ‘decompressive craniectomy’ with all of them aiming at reduction of raised intracranial pressure. We have reviewed the literature and tried to describe the mechanism, various types, indications and complications of this procedure.

Multiple cerebral infarctions with severe multi-organ dysfunction following multiple wasp stings.

Wasp and bee sting are commonly encountered worldwide. Local reactions are more common, generally are self-limiting and settle within a few hours. Multiple stings can lead to various clinical manifestations like vomiting, diarrhea, dyspnea, generalized edema, hypotension, syncope, acute renal failure, and even death. Rarely, they can cause vasculitis, serum sickness, neuritis, and encephalitis. We are reporting a case of 40-year-old male who presented with stroke, right hemiparesis with severe multi-organ dysfunction due to multiple wasp stings.

Decompressive hemicraniectomy in supra-tentorial malignant infarcts.

Background: Decompressive hemicraniectomy not only reduces the intracranial pressure but has been demonstrated to increase survival and decrease the morbidity in patients with supratentorial malignant brain infarcts (STMBI). The aim of this study was to assess the efficacy of surgical decompression to decrease the mortality and morbidity in patients with STMBI refractory to medical therapy and to compare the results with those of the medically managed patients. Methods: All the 24 consecutive patients with clinical and radiological diagnosis of STMBI, refractory to medical management in 2 years, were included. Option of surgical decompression after explaining the outcome, risk and benefits of the procedure was given to the attendants/relatives of all patients who were fulfilling the inclusion criteria. The patient group, whose attendants/relatives were not willing to undergo surgery, were subjected to the same medical therapy and they were taken as the “control group.” Results: Supratentorial malignant infarcts were more common in the age group of 41–60 years. Mean age of presentation was 42.16 ± 16.2 years and the mean GCS on admission was 7.83 ± 2.1. Mortality was 16.7% in the surgically and 25.0% in the medically managed group. Patients operated early (<48 h), age ≤60 years, midline shift <5 mm and size of infarct less than 2/3rd of the vascular territory involved showed good prognosis. The functional outcome revealed by modified Rankin Score (mRS) and Glasgow Outcome Score (GOS) was better in surgically managed patients. Results of the Zung Self-Rating Depression Score were better in surgically managed patients at 1 year. Barthal Index in the surgically managed group showed statistically significant results. Conclusions: Decompressive hemicraniectomy with duroplasty if performed early in STMBI not only decreases the mortality but also increases the functional outcome when compared with patients who were managed conservatively with medical therapy only.

Effect of Fluoxetine on Motor Recovery after Acute Haemorrhagic Stroke: ARandomized Trial

Background: A few clinical trials have suggested that selective serotonin reuptake inhibitors (SSRI’s) enhance motor recovery after stroke but no study has been done in haemorhagic stroke patients. We therefore aimed to investigate whether fluoxetine, an SSRI would enhance motor recovery in patients of haemorrrhagic stroke. Methods: Patients who had haemorrhagic stroke with hemiplegia or hemiparesis and were aged between 18 years and 80 years were included in this double-blind, placebo-controlled trial. Patients were randomly assigned, in a 1:1 ratio to fluoxetine (20 mg/d, orally) or placebo for 3 months starting 5-10 days after the onset of stroke. All patients also had routine physiotherapy. The primary outcome measure was the change on the FMMS between day 0 and day 90 after the start of the study drug. Results: A total of 89 patients were assigned to fluoxetine (n=45) or placebo (n=44), group, and 84 were finally included in the analysis (42 vs 42) after 5 patients lost to follow up. Mean FMMS score improved significantly greater at day 90 in the fluoxetine group (mean 35.64 points) than in the placebo group (23.60 points; p =0.001). Conclusion: Use of fluoxetine in patients of haemorrhagic stroke in early post stroke period added to physiotherapy increased recovery in motor deficits at 3 months.

Brain abscess complicating hemorrhagic contusion in a case of closed head injury: Case report

Brain contusions commonly are identified in patients with traumatic brain injury (TBI) and represent regions of primary neuronal and vascular injury. These edematous lesions contain punctate parenchymal hemorrhages, which are termed micro-hemorrhages. These hemorrhages rarely get infected by hematogenous spread of microorganisms causing a brain abscess. Delayed brain abscess formation in the contusion is a very rare entity. We report a one year old patient who had traumatic right parietal hemorrhagic contusion with no external wound. She was managed conservatively. Two weeks after injury he deteriorated in neurological status and was found to have developed brain abscess. Patient underwent immediate craniotomy with drainage of abscess and excision of abscess wall; she was discharged home after one week. Infective complication can occur rarely even after closed head injury and should be kept as a differential diagnosis in a patient with delayed deterioration.

Association of ACE Gene I/D polymorphism with migraine in Kashmiri population.

Introduction: Migraine is a complex, recurrent headache disorder that is one of the most common complaints in neurology practice. The role of various genes in its pathogenesis is being studied. We did this study to see whether an association exists between ACE gene I/D polymorphism and migraine in our region. Materials and Methods: The study included 100 patients diagnosed with migraine and 121 healthy controls. The study subject were age and gender matched. The analysis was based on Polymerase Chain Reaction (PCR) and included following steps: DNA extraction from blood, PCR and Restriction Fragment Length Polymorphism (RFLP). Results: Out of 100 cases, 69 were females and 31 were males. Fifty-seven were having migraine without aura and 43 had migraine with aura. 45 of the cases had II polymorphism, 40 had ID polymorphism and 15 had DD polymorphism in ACE gene. Conclusion: We were not able to find a statistically significant association between ACE gene I/D polymorphism with migraine. The reason for difference in results between our study and other studies could be because of different ethnicity in study populations. So a continuous research is needed in this regard in order to find the genes and different polymorphism that increase the susceptibility of Kashmiri population to migraine.

Complete ophthalmoplegia: A rare presentation of idiopathic intracranial hypertension.

Idiopathic intracranial hypertension (IIH) is a disorder defined by clinical criteria that include signs and symptoms isolated to those produced by increased intracranial pressure (ICP; e. g., headache, papilledema, and vision loss), elevated ICP with normal cerebrospinal fluid (CSF) composition, and no other cause of intracranial hypertension evident on neuroimaging or other evaluations. The most common signs in IIH are papilledema, visual field loss, and unilateral or bilateral sixth cranial nerve palsy. Here we report a case of IIH presenting as headache with vision loss, papilledema, complete ophthalmoplegia with proptosis in one eye, and sixth cranial nerve palsy in the other eye. Patient was managed with acetazolamide, topiramate, and diuretics. Symptoms remained static and she was planned for urgent CSF diversion procedure.

Posterior reversible encephalopathy syndrome due to seronegative systemic lupus erythematosus

Posterior reversible encephalopathy syndrome (PRES) is a neurotoxic state coupled with a unique computed tomography or magnetic resonance imaging (MRI) appearance. Recognized in the setting of a number of complex conditions (preeclampsia/eclampsia, allogeneic bone marrow transplantation, organ transplantation, autoimmune disease and high-dose chemotherapy) in the imaging, clinical and laboratory features of this toxic state are becoming better elucidated. We are presenting a case of PRES due to seronegative systemic lupus erythematosus, with MRI findings of diffuse vasogenic edema.