Nayil K. Malik

Elevated skull fractures in pediatric age group: Report of two cases

Elevated fractures of the skull, which are rarely reported in the literature, are always compound, have maximal neurological deficits at presentation and have been reported only in adults. We report two cases of elevated skull fractures in the pediatric age group, one of which was a simple elevated fracture and presented with delayed neurological deterioration. The etiologies were a fall in first case and an animal attack (bear maul) in the second case as reported for the first time. One of the cases presented with delayed onset of left focal hemispheric signs. The first case underwent debridement, duraplasty and reduction of fracture whereas in the second case the bone flap was not replaced immediately because of gross contamination. Both patients had an excellent outcome. Elevated skull fractures are not uncommon in the pediatric age group. Compound elevated skull fractures should be managed early as open depressed fractures. Reduction of a simple elevated fracture presenting with neurological deficits not explained by any other lesion can result in a good outcome.

Missile injury to the pediatric brain in conflict zones.

OBJECT This study was conducted both prospectively and retrospectively at one center over a period of 8 years. The population consisted of all patients with both an age 18 years or younger and a diagnosed penetrating missile injury (PMI) during the study interval. The authors analyzed factors determining outcome and demographic trends in this population, and they compared them with those in the more developed world. METHODS Fifty-one patients were the victims of armed conflict, although no one was directly a party to any battle. This mechanism of injury is in strong opposition to data in the literature from developed countries, in which most missile injuries are the result of suicide or homicide or are even sports related. Moreover, all previous studies on the pediatric population have considered only injuries from gunshots, but authors of the current study have included injuries from other penetrating missiles as well. RESULTS On cross tabulation analysis using the chi-square test, the factors shown to correlate with outcome included the Glasgow Coma Scale (GCS) score, pupillary abnormalities, patient age, hemodynamic status, and bihemispheric damage. On multinomial regression analysis, the two strongest predictors of death were GCS score and pupillary abnormalities. The GCS score and hemodynamic status were the strongest predictors of disability. CONCLUSIONS There was no difference in the prognostic factors for PMI between developing or more developed countries. Glasgow Coma Scale score, pupillary abnormalities, and hemodynamic status were the strongest predictors of outcome. In conflict zones in developing countries the victims were mostly innocent bystanders, whereas in the more developed countries homicides and suicides were the leading etiological factors.

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.

Epidemiology of the neural tube defects in Kashmir Valley

Background: Neural tube defects (NTDs) are the most common congenital malformations affecting the brain and spinal cord and have a multifactorial etiology. Genetic and environmental factors have been found to cause these defects, both individually and in combination. Methods: A 2-year hospital-based prospective study was carried out from November 2013 to October 2015 to determine the incidence, types, demographics, risk factors, and other associated anamolies relevant to NTDs in Kashmir Valley. A detailed history of the mother was taken along with detailed clinical examination of neonate including measurement of head circumference and checking the status of fontanella, whether lax/full/bulging/or tense, type of NTD. Investigations that were done included were X-ray skull: Anterior-posterior (AP) and lateral, X-ray spine: AP and lateral, ultrasonography abdomen, magnetic resonance imaging: Spine and brain. Results: The total number of babies with NTDs was 125 with an overall incidence of 0.503. Kupwara district was having the highest incidence (1.047) and Srinagar district the lowest incidence of NTDs (0.197). Majority of NTDs (116 cases, 92.8%) were found in the rural areas. Among the different types of NTDs, spina bifida had an incidence of 0.342 (85 cases, 68%) and anencephaly had an incidence of 0.113 (28 cases, 22.4%). There was a slight preponderance of females over males with NTDs. There were 70 females (56%) and 55 males (44%), respectively, with a male: female ratio of 0.8:1 Conclusions: The incidence rates of NTDs is very high for Kashmir Valley. Geographical distribution of NTDs at this place confirms a relationship between the socioeconomic status, educational status, maternal too young or advanced age, and environmental factors for the development of a NTD. The results of this study point to the importance establishing a health policy to prevent NTD in Kashmir Valley.

EGFR and PTEN Gene Mutation Status in Glioblastoma Patients and their Prognostic Impact on Patient's Survival

Glioblastoma multiforme (GBM) is the most aggressive form of glioma. Genetic analysis of GBM tumorigenesis has identified several alterations in particular EGFR and PTEN genes. The purpose of the present study was to analyze the frequency and distribution of EGFR/PTEN mutations in GBM and to determine their relationship with different clinicopathological characteristics. The paired tumor and adjacent normal tissue specimens of 40 consecutive patients with GBM were examined and DNA preparations were evaluated for the occurrence of EGFR/PTEN gene mutations by PCR-SCCP and DNA sequencing. In total, 20 of 40 (50%) GBM tumours had mutation of either an EGFR or PTEN. EGFR gene mutation was present in 13 (32.5%) and PTEN gene mutations in 07 of 40 (17.5%) patients. Both EGFR/PTEN mutations were found in 03 of 40 samples (7.5%). The samples which showed EGFR mutations but were negative for PTEN were detected in 10 of 40 (25%) patients (EGFR+ve/PTEN-ve). The samples with PTEN +ve/EGFR –ve were present in 04 of 40 (10%) patients. Median PFS and Median OS was better in patients with EGFR +ve/PTEN -ve (p>0.05). EGFR and PTEN gene mutations exist in our population with GBM and play a significant role in its development with better survival for patients for EGFR+ve/PTE –ve mutation status.

Management dilemma in penetrating head injuries in comatose patients: Scenario in underdeveloped countries.

Background: The optimal management of patients with minimal injury to brain has been a matter of controversy and this is especially intensified when the patient has a poor neurological status. This is important in the regions where neurosurgical services are limited and patient turnover is disproportionate to the available resources. We aimed to determine the effectiveness of aggressive management in coma patients after penetrating missile injuries of the brain. Methods: All the patients of gunshots or blast injuries were included if they had a Glasgow Coma Scale score of less than 8 after initial resuscitation and had no other injury that could explain their poor neurological status. The indication for emergency surgery was evidence of a mass lesion causing a significant mass effect; otherwise, debridement was done in a delayed fashion. The patients who were not operated were those with irreversible shock or having small intracranial pellets with no significant scalp wounds. The patients who had a Glasgow outcome score of 1, 2, or 3 were classified as having an unfavorable outcome (UO) and those with scores 4 and 5 were classified as having a favorable outcome (FO). Results: We operated 13 patients and the rest 13 were managed conservatively. The characteristics of the patients having a favorable outcome were young age (OR = 28, P = 0 .031), normal hemodynamic status (OR = 18, P = 0.08), presence of pupillary reaction (OR = 9.7, P = 0.1), and injury restricted to one hemisphere only (OR = 15, P = 0.07). All of the patients who were in shock after resuscitation died while 25% of the patients with a normal hemodynamic status had a favorable outcome. Conclusions: In developing countries with limited resources, the patients who are in a comatose condition after sustaining penetrating missile injuries should not be managed aggressively if associated with bihemispheric damage, irreversible shock, or bilateral dilated nonreacting pupils. This is especially important in the event of receiving numerous patients with the same kind of injuries.

Stray bullet: An accidental killer during riot control

Background: The use of force to control public uprisings, riots, unruly mobs is an important tool in any administrative setup. Law enforcement agencies often resort to aerial firing, which can be responsible for unintended injuries due to stray bullets.This study was designed to study the pattern of stray bullet injuries and to generate awareness about the hazards related to the use of live ammunition during riot control. Methods: This study was conducted in our unit of the neurosurgery department over a period of 18 months, from June 2008 to December 2010. We enrolled all patients who had head or spine injuries caused by stray bullets from firing during riot control far away from the site of injury. Results: We had two patients with head injury and two with spinal injury sustained because of stray bullets. One of the patients with head injury was operated and the other one was managed conservatively; the latter died on the third day of injury, while the former is surviving with some residual neurological deficit. Amongst the patients with spinal injury, neurological deficits persist till date. None of the patients were aware that they had sustained a bullet injury, and it was only after inquiry that we came to know that the police had resorted to aerial firing for controlling public agitation in nearby areas. Conclusion: Aerial firing of live cartridges is generally considered an ‘innocuous’ method; however, in view of the potential for injury to innocent bystanders, we recommend that the use of live cartridges during aerial firing be banned.

Conservative Management of Bomb Shrapnel Injuries to the Brain

AimThis was a prospective study that aimed to analyze the efficacy of conservative management in patients with shrapnel injuries (SI) due to bomb blasts. MethodsPatients with SI to the brain due to bomb blasts during the study period were enrolled in the study. After initial resuscitation, the patients were divided into 2 groups. Group 1 was the one in which patients were managed by supportive care with or without simple wound closure. In group 2, all patients were managed operatively (OM) provided they met the inclusion criteria. ResultsIn the study group, 61 patients with SI due to bomb blasts were enrolled. Out of 61 patients, 46 (75.4%) had favorable outcome and 15 (24.6%) had unfavorable outcome. Of the 45 patients in conservatively managed group, 37 (82.2%) had a favorable outcome whereas 8 (17.8%) had an unfavorable outcome. In the OM group, 9 (56.3%) had a favorable and 7 (43.8%) had an unfavorable outcome. This was mostly because of poor neurologic status of the patients in the OM group. However, the 2 groups did not have a significant difference in postoperative incidence of infections and seizures. ConclusionsThis study is not intended to minimize the importance of surgical management of penetrating missile injuries to the head. Such treatment is most often necessary in cases with definite indications. Conservative management (supportive care) alone or along with simple wound closure is equally effective and has now become an important choice for neurosurgeons facing a large number of casualties, particularly in developing countries.

Clinicopathologic Characteristics of Brain Gliomas: Experience From Culturally and Geographically Distinct Kashmir Valley

Kashmir valley is distinct from rest of India geographically. It has a different climate with people having different social and dietary habits. Cancer pattern in Kashmir is different from rest of India with gastric, esophageal, and skin cancer having a higher prevalence in the valley. No comprehensive study on brain tumors prevalent in the valley is available. To study the pattern of brain tumors, a 3-year retrospective analysis of gliomas was carried out, which are the commonest brain tumors in this population. One hundred and forty gliomas were seen, of which 56 were low grade and 84 were high grade. The clinicopathologic spectrum of gliomas with their outcome was analyzed and it was noted that the spectrum is not different from that reported from rest of India with malignant gliomas as more common and glioblastoma as the commonest tumor accounting for 35% of total gliomas. Among low-grade tumors fibrillary astrocytoma (World Health Organization grade II) accounted for most cases (16.7%). Other tumor types such as oligodendroglioma, oligoastrocytoma, and ependymoma showed a pattern comparable with those occurring in other regions. Radiologic features of gliomas with their outcome were also studied and on analysis these parameters were not different from those reported elsewhere.

Posterior fossa ruptured dermoid cyst presenting with hydrocephalus

Dermoid cysts are rare, benign lesions of embryological origin that represent 0.1-0.7% of all intracranial tumors. They are mainly located in the supra tentorial space, especially in the parasellar region. Their location in the posterior fossa remains uncommon. Rupture of intracranial dermoid cysts is a rare phenomenon. We present a case of dermoid cyst, which had ruptured into ventricular system. Computed Tomography and MRI revealed fat in the fourth ventricle, prepontine cistern, and cerebellomedullary cistern. Hydrocephalus was noted. We performed right ventriculo-peritoneal shunt on which patient improved and he continues to remain asymptomatic one year after.