Navneet Singla

Intracerebral infarcts following clipping of intracranial aneurysms: incidence, clinical correlation and outcome

Subarachnoid hemorrhage (SAH) is a significant health care problem. One of the major determinants of outcome following surgery of intracranial aneurysms is development of intracranial infarcts. All patients underwent clipping for aneurysms in one year in the department of neurosurgery, PGIMER, Chandigarh were studied. Data regarding age, sex, date of ictus, date of admission, any co-morbidity, clinical grades at presentation, CT findings, infarcts, intraoperative rupture, and clinical status in the postoperative period were recorded. Outcome at discharge was assessed by Glasgow outcome scale (GOS). First, 174 patients were included in the study. Radiological cerebral infarctions occurred in 69 patients (39%). The most frequent location of infarct was deep perforator infarct followed by ACA territory infarct. 69.58% of patients developed infarct on the same side of aneurysm and 20.28% of patients developed infarct on opposite side, whereas 11% developed bilateral infarcts. Infarcts that occur early after surgery may be related to surgical factors whereas the late infarcts were probably as results of delayed ischemic deficits. Anatomical distribution of infarcts also showed two different patterns, infarcts limited to one vascular territory (more commonly seen in early onset infarcts) or multiple, cortical, bilateral infarcts (more commonly seen in late onset infarct). Patients with poor H&H grade, higher Fishers grade, intraoperative rupture and prolonged temporarory clipping had more chances of developing an intracranial infarct.

Pediatric Tanycytic Ependymoma of the Cauda Equina: Case Report and Review of the Literature

Tanycytic tumors of the cauda equina region are being increasingly reported. Such tumors can occur among pediatric patients and adults. An unusual case of tanycytic ependymoma located at the region of the cauda equina is reported in a girl. The clinical presentation, radiological features, intraoperative findings, and histopathologic features are described. The prognostic significance of differentiating such a neoplasm from other intramedullary tumors is noted. A heightened awareness of this pathologic entity among neurosurgeons and pathologists will help in diagnosing this neoplasm and in enabling better patient management.

Decompressive craniectomy for malignant cerebral oedema of cortical venous thrombosis: an analysis of 13 patients

Objective. The study aims to define the role and indication of surgical intervention in cases of malignant cerebral edema in consequence to cortical venous thrombosis (CVT). Methods. A retrospective study of 13 patients who underwent decompressive craniectomies for malignant CVT is presented. All patients had supra-tentorial cortical lesions attributable to CVT. The diagnosis was based on CT scan and MRI findings. Patients who presented in a poor clinical status with radiological evidence of malignant cerebral oedema as well as patients who worsened while on medical therapy underwent decompressive hemicraniectomies. Patients were followed up, and the outcome assessed as per Glasgow Outcome Scale (GOS) and Karnofsky Performance Status (KPS) scale. Results. There were nine females and four males with a mean age of 29.2 years. Eleven patients survived with good outcome (GOS = 5, n = 5; GOS = 4, n = 6). At the last follow-up (median 35 months; mean 39 months), the KPS scale was 90 for five, 80 for four and 70 for two survivors. There were two deaths, both in patients with pre-operative Glasgow Coma Scale (GCS) <5. Conclusion. Timely recognition of failure of medical management and an appropriately timed surgical intervention may help to salvage CVT patients who develop malignant cerebral oedema.

Poor-grade subarachnoid hemorrhage: Is surgical clipping worthwhile?

BACKGROUND Management of patients with poor-grade aneurysmal subarachnoid hemorrhage (SAH) is difficult and the protocols followed differ from center to center. MATERIAL AND METHODS In this report, we present our experience with aneurysmal clipping in patients with poor-grade SAH. Patients with poor Hunt and Hess (H and H) grade (Grade IV and Grade V) were offered surgery after stabilization of their hemodynamic and metabolic parameters. The status was recorded as favorable (good recovery, mild to moderate disability but independent), unfavorable (severe disability, vegetative) and dead. RESULTS Out of a total of 1196 patients who underwent aneurysmal clipping, 165(13.8%) were in poor grade. Of the 165 patients, 99 (60%) were in H and H Grade IV and 66 (40%) were in Grade V. More than half of the patients (58%) were operated within 24 h of admission. There was an overall mortality of 50.9%. In the long term, of the survivors who were followed up, about 72% achieved a favorable outcome. CONCLUSIONS With an aggressive approach aimed at early clipping, the chances of rebleed are reduced and vasospasm can be managed more aggressively. This protocol resulted in survival in a significant proportion of patients who would have otherwise died. In the long-term follow-up, the surviving patients showed significant improvement from the status at discharge.

Study of factors determining caregiver burden among primary caregivers of patients with intracranial tumors.

Background: Caregivers of patients with intracranial tumors handle physical, cognitive, and behavioral impairments of patients. The purpose of this study was to assess the magnitude of burden experienced by primary caregivers of patients operated for intracranial tumors and evaluate factors influencing it. Methods: Descriptive cross-sectional design was used to assess home-care burden experienced by primary caregivers of patients operated for intracranial tumors. Using purposive sampling, 70 patient-caregiver pairs were enrolled. Modified caregiver strain index (MCSI) was used to assess the caregiver burden. Mini mental status examination (MMSE), Katz index of independence in activities of daily living (ADL), and neuropsychiatric inventory questionnaire (NPI-Q) were used to assess the status of patients. Results: Of 70 caregivers, 45 had mild, and 22 had moderate MCSI burden. A number of behavioral changes in NPI-Q had a significant correlation with MCSI burden (P < 0.001), whereas MMSE and Katz-ADL of patients did not show significant relation with caregiver burden. In NPI-Q, irritability, agitation, anxiety, depression, and sleep disturbances had a significant impact on MCSI. Among caregiver factors, unemployment, low per capita income, time spent, inability to meet household needs, quitting the job, and health problems had a significant impact on MCSI. In separate multivariate analyses, irritability component (P = 0.004) among behavioral changes of patients and caregivers’ inability to meet household needs (P < 0.001) had a significant association with caregiver burden independent of other factors. Conclusions: Behavioral changes in patients (especially irritability) and financial constraints had a significant independent impact on the burden experienced by primary caregivers of patients operated for intracranial tumors. Identifying and managing, these are essential for reducing caregiver burden.

The effect of cranioplasty following decompressive craniectomy on cerebral blood perfusion, neurological, and cognitive outcome

OBJECTIVE Decompressive craniectomy is an established therapy for refractory intracranial hypertension. Cranioplasty following decompressive craniectomy not only provides protection to the brain along with cosmetic benefits, but also enhances rehabilitation with meaningful functional recovery of potentially reversible cortical and subcortical damaged areas of the affected as well as the contralateral hemisphere. The aim of the study was to assess neurological and cognitive outcome as well as cerebral blood flow after cranioplasty. METHODS Thirty-four patients admitted for replacement cranioplasty after decompressive craniectomy for head injury were studied prospectively. Clinical, neurological, and cognitive outcomes were assessed by the Glasgow Outcome Scale (GOS), the Glasgow Coma Scale, and a battery of cognitive tests, respectively. Simultaneously, cerebral blood perfusion was assessed by technetium-99m ethyl cysteinate dimer (99mTc-ECD) brain SPECT imaging 7 days prior to and 3 months after cranioplasty. RESULTS Prior to cranioplasty 9 patients (26.5%) had GOS scores of 5 and 25 patients (73.5%) had GOS scores of 4, whereas postcranioplasty all 34 patients (100%) improved to GOS scores of 5. Approximately 35.3%-90.9% patients showed cognitive improvement postcranioplasty in various tests. Also, on comparison with brain SPECT, 94% of patients showed improvement in cerebral perfusion in different lobes. CONCLUSIONS Cranioplasty remarkably improves neurological and cognitive outcomes supported by improvement in cerebral blood perfusion.

CSF fistula through the umbilicus following a shunt surgery: a case report and literature review.

Background: Ventriculoperitoneal shunting is among the commonest neurosurgical operations. Shunt catheters within the peritoneal cavity have migrated through and perforated almost all the intra-abdominal hollow viscera. Case Description: A unique case of an infant is presented, in whom CSF leaked via a fistulous opening through the umbilicus. The embryological aspect of this anomalous communication is described, along with all the 7 cases previously reported with their pathophysiological causes. Conclusions: The CSF fistula through the umbilicus may be due to varying pathological causes. The present paper describes an altogether new pathological cause behind such a complication, with a re-visit to all other described causes. The present description of a patent intercoelomic communication, an embryological remnant, puts a new light on this 3-decade-old complication.

An orphan disease: IgG4-related spinal pachymeningitis: report of 2 cases.

IgG4-related disease is relatively new disease entity and a rare one, and our knowledge of this entity continues to evolve. It was first described in the pancreas and since then has been described in virtually every organ. Spinal involvement resulting in pachymeningitis is rare, and there are only 8 reported cases of the same to date, with the cervicothoracic spine being the most commonly affected region. The authors describe 2 cases in which the patients presented with spinal compression resulting in myeloradiculopathy (Case 1) and radiculopathy (Case 2). Imaging of spine in both cases revealed an ill-defined contrast-enhancing lesion at the lumbar level. Preoperatively, a diagnosis of spinal tumor was made, but intraoperatively no spinal tumor was found. The diagnosis was established histopathologically. The disease has no particular defining features clinically or radiologically and can mimic common spinal tumors. It is important to accurately diagnose this rare entity because of its multisystem involvement and progressive course. Strict treatment guidelines have yet to be formulated. Although histologically this disease can mimic other inflammatory conditions, the presence of storiform fibrosis and an increased number of IgG4-positive plasma cells can help in clarifying the diagnosis.

Hemorrhage in astroblastoma: An unusual manifestation of an extremely rare entity.

Astroblastoma is a rare tumor of glial origin with characteristics of both astrocytoma and ependymoma. It is usually seen in children and young adults, and is peripherally located, well circumscribed, of solid-cystic composition and with heterogeneous contrast enhancement. Histopathology reveals perivascular pseudorosette formation and thick hyalinised vessels. Hemorrhage in astroblastoma is unusual and rarely described in literature. We report two patients with astroblastoma who presented with hemorrhage and discuss the natural history, radiological findings, pathophysiology of hemorrhage and histopathological characteristics. We emphasize the importance of early suspicion in peripherally located lesions with bleeding.

Giant intraparenchymal neurocysticercosis: Report of surgical aspects two cases

Giant parenchymal cysticercosis is a relatively rare condition and surgical treatment may be required when it is associated with elevated intracranial pressure. We report two patients with giant parenchymal cysticercosis who were treated surgically for the elevated intracranial pressure. In both the patients the preoperative diagnosis was of a cystic glioma. Total excision of the lesions was achieved in both the patients. In countries endemic to neurocysticercosis gaint parenchymal cysticercosis should be considered in the differential diagnosis of cystic enhancing mass lesion. Surgical excision may be indicated when it is associated with elevated intracranial pressure.