Rajesh Chhabra

Nonaneurysmal nonperimesencephalic subarachnoid hemorrhage: is it a benign entity?

BACKGROUND Although the clinical profile of patients with PMN SAH is well documented, there are scarce data available for patients with nonaneurysmal n-PMN SAH. In the present study, the clinical characteristics of patients with n-PMN SAH were analyzed and compared with those of PMN SAH and aneurysmal SAH. METHODS Patients with spontaneous SAH, in whom the initial DSA or 3-dimensional CTA result was normal, underwent another investigation (CTA/DSA). If the results of both of these were negative, a second DSA was done after 4 to 6 weeks. Patients in whom even the second DSA failed to reveal an aneurysm or any other vascular abnormality were labeled as nonaneurysmal SAH. Within this group, 2 different types were identified: PMN SAH and n-PMN SAH. RESULTS There were 61 patients in whom the results of the first DSA and CTA were both negative. In 2 of these patients, an aneurysm was demonstrated at a second DSA. Seven patients died before a second DSA could be done. After excluding these, there were 18 patients with PMN SAH and 34 with n-PMN SAH. There was no mortality in these patients; and at a mean follow-up of 1.8 years, all patients with PMN SAH and 94.1% of patients with n-PMN SAH had a good outcome. Associated comorbid illnesses were more frequent in patients with PMN SAH and n-PMN SAH as compared with the aneurysmal SAH patients. CONCLUSIONS Once an aneurysm is definitely excluded, patients with n-PMN SAH have a good outcome, and like PMN SAH, have a benign clinical course. However, a second DSA is mandatory to avoid missing an aneurysm or any other vascular lesion.

Decompressive surgery for acute subdural haematoma leading to contralateral extradural haematoma: a report of two cases and review of literature.

Development of a contralateral epidural haematoma during or immediately after cranial surgery is a well-described entity. However, in a case of acute subdural haematoma where the brain is usually tense, postoperative development of contralateral extradural haematoma is uncommon. We report two cases of contralateral extradural haematoma after decompressive surgery for acute subdural haematoma. We recommend routine postoperative CT immediately after cranial surgery for head trauma. This would help in timely detection and treatment of such a complication.

Tuberculosis of the craniovertebral junction: is surgery necessary?

OBJECTIVE:Tuberculosis of the craniovertebral junction is an uncommon entity and its optimal management remains controversial. In this study, we present the evolution of management protocol of this disease in our institute in the past 3 decades. METHODS:A total of 51 patients with craniovertebral junction tuberculosis presenting as atlantoaxial dislocation from 1978 through 2004 were reviewed. The disease was rated from Stage I to Stage III, depending on the radiological findings. All patients received antitubercular treatment for 18 months. In the initial period of this study (1978–1986), all patients (n = 10) underwent surgery, usually a posterior fusion. In the second period (1987–1998), patients with less severe disease (Stages I and II, n = 14) were managed with external rigid immobilization, whereas patients with severe disease (Stage III, n = 11) underwent either a transoral decompression with or without posterior fusion or posterior fusion alone. More recently (1999–2004), all patients (n = 16) in all stages (Stages I–III) have been managed without surgery by a rigid external immobilization. RESULTS:Except for two patients who died (one because of miliary tuberculosis, the other because of acute hydrocephalus), clinical recovery occurred in all. Follow-up imaging demonstrated radiological healing as well, with regrowth of the destroyed bone. CONCLUSION:The mainstay of management of tuberculosis of the craniovertebral junction is prolonged antitubercular treatment with a rigid external immobilization. Surgery is not necessary, even in patients with advanced stages of disease. Complete clinical and radiological healing occurs in all patients with conservative treatment.

Posterior midline approach for large anterior/anterolateral foramen magnum tumours

The standard surgical approaches described for excision of anterior or anterolaterally placed foramen magnum (FM) tumours are the far lateral approach, the extreme lateral approach and the transoral approach. In general the posterior midline approach is considered not suitable for these lesions. We have operated on 27 patients with benign anterior/anterolaterally placed FM tumours in the last 8 years. Thirteen of these were operated via the posterior midline approach. All these 13 patients had large or giant tumours displacing the cervicomedullary region posteriorly and laterally. This allowed adequate access through this approach with minimal handling of neural tissue. For small lesions, the far lateral approach was used. Most of the patients improved significantly neurologically. We recommend the standard midline posterior approach for large/giant FM tumours as the tumour size itself provides enough working space for the surgeon. For small lesions, the far lateral approach is preferred.

Vertebral cryptococcosis simulating tuberculosis

Infection with the fungus Cryptococcus neoformans is seen predominantly in two forms: (a) pulmonary and (b) cerebromeningeal. Skeletal cryptococcosis is uncommon. There have been only occasional case reports of thoracic vertebral cryptococcosis presenting as cord compression. A young female had cervical lymphadenopathy diagnosed as tuberculosis by fine needle aspiration cytology (FNAC) and was on antitubercular therapy (ATT) for 5 months. She developed rapidly progressive paraparesis and imaging demonstrated a destructive vertebral body lesion involving T2 – 3 with a paraspinal abscess producing cord compression. A costotransversectomy with excision of the diseased bone and bone grafting was done. Histopathological examination revealed cryptococcosis. The patient was put on antifungal medication, but expired 2 weeks after surgery. Radiological, magnetic resonance imaging and surgical finding of vertebral cryptococcosis can mimic tuberculosis. The definite diagnosis of cryptococcosis depends upon microscopic identification of the organism. A high index of suspicion leading to early surgical confirmation and institution of anti fungal therapy is necessary to reduce the mortality and morbidity.

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.

Comparison of Small Dose Ketamine and Dexmedetomidine Infusion for Postoperative Analgesia in Spine Surgery--A Prospective Randomized Double-blind Placebo Controlled Study.

Background: High doses of opioids are frequently used to treat postoperative pain after spine surgery. This leads to opioid-related side effects like nausea, vomiting, respiratory depression, etc. The current study is an attempt to find a safe analgesic adjuvant, which will afford opioid sparing property. Method: Sixty-six patients undergoing spine surgery were randomized into 1 of the 3 groups—group K (ketamine bolus 0.25 mg/kg followed by infusion of 0.25 mg/kg/h with midazolam bolus 10 &mgr;g/kg and infusion of 10 &mgr;g/kg/h mixed in the same infusion pump), group D (dexmedetomidine bolus 0.5 &mgr;g/kg followed by 0.3 &mgr;g/kg/h infusion), and group C (normal saline). Study drugs were started in the postoperative period and continued for 24 hours. Pain-free period, pain scores, rescue analgesic (morphine) requirements, and side effects were noted for 48 hours postoperatively. Result: Mean pain-free periods in the ketamine group (860 min) and the dexmedetomidine group (580 min) were longer than in the saline group (265 min) (P<0.002) during the observation period of 48 hours. There was a significant decrease in the rescue analgesic requirement in both ketamine and dexmedetomidine group (P<0.05) (cumulative morphine requirement at 24 h—group C 15.64±9.31 mg, group D 6.89±5.88 mg, group K 2.45±2.06 mg; at 48 h—group C 21.09±12.88 mg, group D 7.98±7.72 mg, group K 2.59±1.97 mg). Hemodynamics were maintained within normal range in all the groups. Patients in ketamine and dexmedetomidine groups were sedated, but none required assistance for maintaining airway patency. Few patients in the ketamine group had nausea, dizziness, and diplopia, but the difference was insignificant in comparison with other groups (P>0.05). Conclusions: Infusion of low-dose ketamine and dexmedetomidine both provide good postoperative analgesia with minimal side effects. Both of the tested analgesic regimes can be used safely and effectively for postoperative pain relief in patients after spine surgery.

Incidence, risk factors, and outcome of postoperative pneumonia after microsurgical clipping of ruptured intracranial aneurysms.

Background: Occurrence of pneumonia challenges the medical management of patients who have undergone surgery for aneurysmal subarachnoid hemorrhage, and is associated with significant mortality and morbidity. There are very few studies evaluating the incidence and outcome of postoperative pneumonia in patients undergoing microsurgical clipping of ruptured intracranial aneurysms. The aim of this study was to determine the incidence, risk factors, and outcome of postoperative pneumonia in patients undergoing surgery for ruptured intracranial aneurysms. Methods: All patients operated for intracranial aneurysms, over a period of 9 months, were included prospectively. They were studied for risk factors predisposing them to pneumonia and their outcomes were noted at discharge. Patients with predisposing chronic lung disease, preexisting pneumonia, and chronic smoking habits were excluded. Results: One hundred and three patients [Mean age: 46.01 years; M:F – 58:45] underwent microsurgical clipping of aneurysm during the study period. Of these, 28 patients (27.2%) developed postoperative pneumonia. The variables associated with postoperative pneumonia were: [Preoperative] age >50 years, Glasgow Coma Scale (GCS) at presentation <15 and Hunt and Hess grade before surgery >2; [postoperative] duration of surgery >3 hours, GCS <15 after complete reversal from anesthesia, duration of intubation in the postoperative period >48 hours, tracheostomy, postoperative ventilation, intensive care unit (ICU) stay >5 days. Predictive factors for postoperative pneumonia by multivariate analysis were: Postoperative endotracheal intubation >48 hours, tracheostomy and ICU stay >5 days. Conclusions: There is a high incidence of postoperative pneumonia and mortality associated with pneumonia (27.2% and 9.7%, respectively in our study) in patients of ruptured intracranial aneurysms undergoing microsurgical clipping at our center, with Acinetobacter species being the predominant causative organism.

Infected Intraparenchymal Dermoids: An Underestimated Entity

Infection secondary to a dermal sinus most commonly occurs in the form of cutaneous, epidural, or subdural abscesses. Rarely, it can result in an intramedullary abscess as a result of a dermal sinus. This study presents a clinicoradiological profile of 19 cases harboring abscesses within the dermoids and highlights the importance of dermal sinus acting as a pathway for infections to enter the nervous system. Emergent exploration, pus drainage, and minimal abscess wall excision along with prolonged antibiotic administration remained the management of choice in all cases. Methicillin-sensitive Staphylococcus aureus was the commonest offending organism. In all, 7 patients recovered to normal neurological status, 5 showed no improvement, and 7 improved partially. Improvement in motor power was noted, albeit partially, but bladder functions failed to recover even at long-term follow-up. Even when such infective complications of dermal sinuses are rare, these are potentially serious and disabling.

Orbital roof growing fractures: a report of four cases and literature review.

Trivial injuries among paediatric patients are usually underestimated. Such injuries may account for delayed problems such as growing fractures of skull vault. Growing fracture of the orbital roof is rarely reported. Four cases of paediatric cranial trauma with growing orbital roof fractures are presented. Three cases required only dural repair, while the fourth patient underwent both duraplasty and cranioplasty, due to a large orbital roof defect. At follow-up, all had satisfactory outcome. Trivial injuries among children should be evaluated with caution. The development of orbital symptomatology should ask for a complete radiological survey. The orbital roof growing fractures are potentially important cause of orbital problems. The dural repair alone, usually provides satisfactory outcome, while calvarial bone graft may be of help in cases with large bony defects. Early diagnosis and management of such cases may prevent permanent neurological deficits.