Nitin Mukerji

Subarachnoid Hemorrhage Patients' Fears of Recurrence Are Related to the Presence of Posttraumatic Stress Disorder

BACKGROUND:Subarachnoid hemorrhage (SAH) patients illustrate a chronic fear of recurrence. A third of patients develop posttraumatic stress disorder (PTSD) after SAH, and PTSD after other conditions is associated with a more negative outlook on life. OBJECTIVE:We examined whether recurrence fears are related to PTSD and whether this is associated with the patients making more negative health appraisals. We also examined the helpfulness of current treatments. METHODS:Two SAH samples were generated. Sample 1 (n = 82) was assessed 13 months after ictus for PTSD, cognition, fear of recurrence, and beliefs concerning future health. Sample 2 (n = 60) was assessed 18 months after ictus for PTSD and to determine how much current treatments increased their confidence about not having another SAH. RESULTS:Thirty-four percent of sample 1 had PTSD. Although clinically and cognitively comparable, PTSD patients feared recurrence more and were comparatively more pessimistic about their chances of further SAH. Thirty-six percent of sample 2 had PTSD. These most fearful patients reported finding current treatments the least helpful. CONCLUSION:Fear of recurrence after SAH is related to PTSD. Participants with PTSD were more pessimistic about their future health. Treatment for PTSD could alleviate fears of SAH recurrence and promote better outcome.

Spinal epidural haematoma; factors influencing outcome

Abstract Objective. Spinal epidural haematoma (SEH) causing spinal cord compression is potentially a cause of long-term neurological disability. We reviewed the relevant literature with the intention of establishing the factors that influence long-term outcome and the timeframe within which operative intervention must be undertaken for optimal results. Methods. A total of 1177 papers were identified using PubMed among which 31 papers were selected and analysed. The grades of neurological deficit, pre- and post-operatively, were classified according to the Frankel grade. The timing of surgery was from the onset of first symptoms of incomplete cord lesions and the onset of paraplegia with complete lesions. Results. The two main factors that determine long-term outcome were the degree of neurological deficit at the time of treatment and the timing of surgical intervention. Fifty-six per cent of patients who had ‘incomplete SCI’ made a full neurological recovery as compared to 27% when the initial injury was ‘complete SCI’ (Chi square, p < 0.001). Operative intervention within 12 h of onset of symptoms gave the best chance of recovery to ‘normal’ (Frankel E), even in patients who were paraplegic (Frankel A) pre-operatively. Conclusion. Recovery to ‘normal’, or ‘incomplete SCI’, is possible with surgical decompression if performed within 12 h, even if the patient is paraplegic pre-operatively. If the diagnosis is suspected, immediate investigations must be undertaken and/or arrangements for appropriate referral must be made urgently to ensure diagnosis and treatment in the tertiary centre within the 12 h window.

Neuropsychologic Impact of Treatment Modalities in Subarachnoid Hemorrhage: Clipping Is No Different from Coiling

OBJECTIVE This study assesses the impairment in activities of everyday life using a novel test battery following subarachnoid hemorrhage (SAH) and its treatment. METHODS A one-off neuropsychologic assessment was conducted for all patients who agreed to participate in the study. The date of the interview was at least 12 months after the ictus. The aspects tested included attention, memory, mood, and executive functions. Thirty normal subjects were also assessed using the same battery of tests to act as controls. The data was analyzed using JMP, version 8.0.2. The project was approved by the local research ethics committee and was performed under the tenets of the Helsinki declaration. RESULTS Analysis from 77 patients and 30 controls is presented. Patients in the SAH group had significant deficits of sustained attention and attentional switching and executive functions when compared to normal controls (P < 0.05, χ(2)). Within the SAH patient group, the deficits were independent of the subgroup to which the patients belonged (coiled, clipped, and perimesencephalic hemorrhage, P > 0.05, χ(2)). The perimesencephalic hemorrhage group had fewer deficits as compared to the coiled and clipped groups, but because there were very few patients in this group, statistical significance was not achieved for these results. CONCLUSION Our results reflect a change in UK practice in treating aneurysms, the majority being treated with endovascular coiling. After more than 12 months postictus, attention and executive functions were found to be significantly impaired. Significant deficits remain in various cognitive domains following an SAH, but these appear to be independent of the treatment modality according to our data.

Factors affecting diagnostic yield in needle biopsy for brain lesions

Abstract Introduction. We analyse the factors that are associated with the diagnostic yield of needle brain biopsy. Material and methods. We present a retrospective series of 124 consecutive biopsies in a 30-month period. Patients’ demographics (age, gender), lesion topography (side, location, depth), lesion characteristics (histology, volume, radiological enhancement), type of biopsy procedure (freehand, ultrasound guided, frameless and frame-based stereotactic) and the use of intraoperative histologic examination were correlated with the diagnostic rate. Descriptive statistics and a nominal logistic regression model were used to evaluate the factors influencing diagnostic yield. Results. 63 men and 61 women were included in the study with mean age 59.2 (range: 16–86). 55 were frame-based stereotactic biopsies, 33 were frameless stereotactic biopsies, 29 biopsies were performed under ultrasound guidance and 7 freehand. The diagnostic yield in our series is 93.5%. The gender, lesion topography, biopsy method, use of intraoperative histology and enhancement did not correlate with the diagnostic yield. Younger age had a negative impact on diagnostic yield. 6 out of 8 inconclusive biopsies were in non-glial lesions (p < 0.05). The odds of obtaining a positive diagnosis increased sevenfold with every cc increase in lesion volume. Conclusion. The age of the patient, the volume and the histology of the brain lesion had an impact on the diagnostic yield of needle biopsy. None of the other factors significantly influenced the diagnostic rate.

Hemifacial spasm as a feature of Chiari malformation: case report.

BACKGROUND AND IMPORTANCE: Hemifacial spasm has rarely been described as one of the presenting features of Chiari I malformation. We present a case in which we found an association between the two in the absence of a basilar impression. CLINICAL PRESENTATION: A case of a 39-year-old man who presented with a disabling hemifacial spasm and was found to have Chiari I malformation as the possible cause is described. A foramen magnum decompression successfully relieved the hemifacial spasm. The patient remains symptom free at 20 months after the operation. CONCLUSION: Neurosurgeons may want to consider foramen magnum decompression as first-line surgical treatment for hemifacial spasm when it coexists with Chiari I malformation. Chiari I malformation should be considered one of the rare causes of hemifacial spasm.

Ruptured cerebral aneurysm in a patient with Floating-Harbor syndrome.

Introduction Floating-Harbor syndrome is a rare syndrome first described by Pelletier and Feingold (1973) in a boy seen at the Boston Floating Hospital and by Leisti et al. (1975) in a patient at the Harbor General Hospital in Torrance, California. The syndrome is characterized by the presence of short stature with significantly delayed bone age, delay in expressive speech usually in the presence of normal motor development and dysmorphic facial features (Robinson et al., 1988; Patton et al., 1991). Further case reports described other associated features like feeding difficulties, fifth finger clinodactyly, finger clubbing, clavicular pseudarthrosis, coeliac disease (Chudley and Moroz, 1991), high-pitched voice, congenital heart disease (Patton et al., 1991; Lazebnik et al., 1996; Hersh et al., 1998), genitourinary anomalies (Pelletier and Feingold, 1973; Leisti et al., 1975) and spinal dysraphism (Wiltshire et al., 2005). The association of Floating-Harbour syndrome and cerebral aneurysms has never been reported before.

Flow dynamics in lumboperitoneal shunts and their implications in vivo

OBJECT Lumboperitoneal shunting is the standard treatment for pseudotumour cerebri or idiopathic intracranial hypertension. Complications are common, particularly the problem of overdrainage leading to low pressure symptoms. The authors designed a simple experiment using catheters of different lengths that drained at different pressure heads and with different vertical drops to study the flow characteristics in these shunts and determine the optimal catheter placement and length that would reduce the occurrence of low pressure headaches. METHODS The flow rates through catheters of 3 different lengths (60, 83, and 100 cm) with the same internal radius, at 3 different pressure heads (15, 25, and 35 cm H2O to simulate 3 different placements in the lumbar theca), and 3 different vertical drops (10, 20, and 30 cm to simulate the possible effect of siphoning) were measured and the results analyzed. RESULTS Application of Poiseuilles law and Bernoullis principle to the experimental design shows that the volume of flow is directly proportional to the sum of the pressure head and the vertical drop and inversely proportional to the length of the catheter. The flow rate through the standard catheter lengths over the course of 24 hours can be abnormally high. An attempt to predict the optimal catheter length was made. CONCLUSIONS Although the catheter position in the theca and abdomen cannot be altered significantly and the internal radius of the tube cannot be reduced further without increasing the risk of blockage, the length of the tube can be increased to combat overdrainage. The authors suggest that currently available catheters are too short.

Carotid endarterectomy—safe and effective in a neurosurgeon's hands: a 25-year single-surgeon experience.

OBJECTIVE Carotid endarterectomy (CEA) is a procedure performed by both vascular surgeons and neurosurgeons in the UK. We present a single neurosurgeons experience of 728 CEAs over 25 years, performed under both general and local anesthesia, and discuss the results in this context. Our objective was to report on the efficacy of CEA in the hands of a neurosurgeon. METHODS Prospective outcome data were collected for all patients who underwent CEA performed by the senior author (A.D.M.) from 1987 to 2011. Data evaluated included patient age, sex, surgical indication, preoperative characteristics, diagnostic modalities used, shunt usage, operative time, any neurological deterioration during or after surgery, and early postoperative problems. Outcome measures used were 30-day death and 30-day disabling stroke. The results were tabulated and analyzed using JMP 8.0.2 (SAS Inc., Cary, NC). RESULTS The 30-day death rate was 0.8% and the 30-day disabling stroke rate was 1.7% in our series. The mean operative time was 135 minutes (±38.1), and the mean clamp time was 28.4 minutes (±8.5). In the subset of patients who had the operation performed under local anesthesia (n = 616), the disabling stroke rate was 1.6% and the death rate was 0.6%. In the subset of asymptomatic patients (n = 194), the 30-day death and 30-day disabling stroke rates were each 1%. Postoperative complications were uncommon. CONCLUSIONS According to our data, CEA under local anesthesia is safe procedure in the hands of a neurosurgeon and would be recommended according to the clinical presentation and local guidelines.

Using telephone logs instead of databases to accurately estimate neurosurgical on-call workload.

Abstract Background. Maintenance of on-call referrals databases is on the rise in neurosurgical units across the UK and helps provide data to estimate workload. We hypothesize that these databases underestimate the workload and propose the use of the number of telephone calls to the on-call registrar as an easily obtainable and valid measure of workload. Methods. Data were obtained from a referrals database maintained and completed by the neurosurgical registrars and the hospital switchboard telephone logs. Data were analysed using JMP 8.0.2 (SAS Institute, Cary, NC). Results. We found a large degree of disparity between the number of phone calls and the number of recorded referrals. The median number of phone calls to the on-call registrar per day was 78 (Interquartile range 59–106); but the median number of recorded referrals was 12 (Interquartile range 8–16). 49.8% of the calls were received out-of-hours (1700–0800 and weekends) and the maximum number of calls was received on a Friday. Data derived from both sources (database and switchboard logs) showed a close visual correlation. Conclusion. We argue that on-call logs are an easily obtainable, reliable and internally validated measure of activity. We recommend the use of such data in other centers to establish the nature of on-call activity and tailoring of the rotas to comply with current guidance to provide a mix of service and training.

Spinal Cord Stimulation for Visceral Pain Related to Chronic Pancreatitis: Report of 2 Cases

OBJECTIVE To report our experience related to the use of spinal cord stimulation (SCS) for relief of chronic pancreatitis-related neuropathic visceral pain. METHODS Two patients, 50 years old and 39 years old, presented with intractable visceral pain related to chronic pancreatitis. A quadripolar electrode for SCS was inserted at the T8-10 level using a percutaneous technique. After a successful trial, a permanent stimulator was inserted. RESULTS At a mean follow-up of 7 years, both patients showed a marked improvement, with 80% and 90% decrease of pain, respectively, as assessed by Visual Analogue Scale. Pain medications were discontinued in both cases. CONCLUSIONS SCS appears to be an effective long-term treatment for neuropathic visceral pain related to chronic pancreatitis.