Mohan R. Sharma

Neurosurgery at Tribhuvan University Teaching Hospital, Nepal

FEBRUARY 6, 2005, marks the 10th anniversary of the first neurosurgical procedure performed at Tribhuvan University Teaching Hospital, one of only a few tertiary-care hospitals in Nepal. Neurosurgery began at the hospital with the arrival of an American neurosurgeon to train Nepalese surgeons locally and, later, the return of these Nepalese surgeons to Kathmandu after subsequent fellowship training in the United States. This article traces the origins of neurosurgery in Nepal, outlines the specialty’s development in Kathmandu at Tribhuvan University Teaching Hospital during the past decade from international education strategies, and describes the status of and challenges facing the provision of neurosurgical care in Nepal. The role of neurosurgical services in improving the health care status of populations in developing countries is considered. Neurosurgeons in developing and developed countries alike should continue to work to remedy the inequitable distribution of neurosurgical knowledge and services throughout the world.

Pediatric Central Nervous System Tumors in Nepal: Retrospective Analysis and Literature Review of Low- and Middle-Income Countries.

BACKGROUND Central nervous system (CNS) tumors are the most common cause of cancer-related death in children. Little is known about the demographics and treatment of pediatric brain tumors in low- and middle-income countries (LMICs). METHODS We performed a retrospective chart review of all pediatric patients who presented to the neurosurgical service at Tribhuvan University Teaching Hospital in Kathmandu, Nepal from 2009-2014 and collected information on patients <18 years old who received a diagnosis of a CNS tumor. We analyzed age, gender, clinical presentation, extent of surgical resection, histopathology, and length of hospital stay. We also conducted a literature review using specific terminology to capture studies of pediatric neuro-oncologic epidemiology conducted in LMICs. Study location, length of study, sample size, study type, and occurrence of 4 common pediatric brain tumors were extracted. RESULTS We identified 39 cases of pediatric CNS tumors, with 62.5% observed in male children. We found that male children (median = 13 years) presented later than female children (median = 8 years). The most frequently observed pediatric brain tumor type was ependymoma (17.5%), followed by astrocytoma (15%) and medulloblastoma (15%). Surgical resection was performed for 80% of cases, and gross total resection reported in 62.9% of all surgeries. More than half (54.1%) of patients had symptoms for more than 28 days before seeking treatment. Symptomatic hydrocephalus was noted in 57.1% of children who presented with CNS tumors. The literature review yielded studies from 18 countries. Study length ranged from 2-20 years, and sample sizes varied from 35-1948. Overall, we found more pronounced variation in the relative frequencies of the most common pediatric brain tumors, compared with high-income countries. CONCLUSIONS We present the first operative series of childhood CNS tumors in Nepal. Children often had delayed diagnosis and treatment of a tumor, despite symptoms. More comprehensive data are required to develop improved treatment and management algorithms in the context of a given countrys demographics and medical capabilities for childhood CNS tumors.

Shifting paradigm in brain abscess management at tertiary care centre in Nepal

Aim: Brain abscess is a challenging clinical entity with substantial high case fatality rates despite significant advances in imaging techniques, laboratory modalities, surgical interventions, and antimicrobial treatment.Otogenic and cardiogenic sources are among the most common. Classic clinical presentation is seen in very few cases only. Burr hole with aspiration works well with good clinical outcomes. Control of primary source in cases of ear infection in the single setting results in good outcomes, reduces for additional surgery, and decreases the duration of hospital stay. Methods: This is prospective observational study conducted at Institute of Medicine, Tribhuvan University Teaching Hospital, Kathmandu, Nepal over the period of two and a half years (from September 2014 to March 2017).We analyzed the demographic profile, management strategies and outcome of these cases diagnosed with brain abscess using Microsoft Excel 2007. Results: A total of 51 cases were undertaken for surgical management. There were 35 males and 16 females with the male to female ratio of 2.18:1. The mean age of the study population was 16.76 years with age range from 4 months to 60 years. Otogenic source was the most common. Temporal lobe was the most common abscess location. Headache was the most common clinical presentation and was seen in 86.27% of the study population. All cases were initially managed with burrhole and aspiration of the abscess. Only 3.92% (n = 2) of cases subsequently required surgical excision of the abscess wall. Only 11.76 % (n = 6) of the cases required multiple aspiration. Only 19.61% (n = 10) showed positive culture. Pseudomonas aeruginosa and E. coli were the most common organisms grown. Mortality rate among the study group was 3.92%. Conclusion: With the advent of modern technology in neuroimaging, mortality due to brain abscess has significantly decreased. Joint involvement of the otorhinolaryngology team and efforts in addressing the primary source have further helped in improving outcomes in cases of otogenic brain abscess. Hence, source control is of paramount importance in managing the brain abscess.

Cervical Osteoblastoma: A Rare Primary Spinal Tumor

Osteoblastoma is a rare and benign osteoid producing primary bone tumor that affects mainly the long bones. It makes 5% of spinal tumors, mostly arising within the posterior elements of the spine within the second and 3rd decades of life. We managed an 18 year old patient with osteoblastoma of C6 vertebra. Nepal Journal of Neuroscience 13:51-53, 2016

Subarachnoid Hemorrhage Following Masturbation: The Significance ofEliciting Detail Clinical History

A 36 years old patient presented with severe headache of 4 hours duration, not relieved with non-steroidal anti-inflammatory agents. He did not have history of loss of consciousness or trauma. His Glasgow Coma Scale score was 15, oriented to time, place and person and with intact cranial nerves. Neck rigidity and fever were absent. His blood pressure was 140/80 mm Hg. Laboratory investigation reports including the platelet count and prothrombin time were normal. Detail history revealed that the headache had started abruptly just after ejaculation during masturbation while bathing. CT scan of the head revealed subarachnoid hemorrhage (Figure 1). Patient was transferred to high volume centre. CT cerebral angiography revealed saccular aneurysms arising from bilateral ophthalmic segments of internal carotid arteries (Figure 2). Both the aneurysms were secured by clipping after around 48 hours of ictus and the patient had uneventful recovery with no residual neurological deficits. Patient had no residual neurological deficits when he attended the hospital clinic 3 months after the ictus.