Sajad Arif

Albendazole as an adjuvant to the standard surgical management of hydatid cyst liver

BACKGROUND The treatment options for hydatid cyst liver include non-operative and operative methods. Operative methods include conservative and radical procedures. Non-operative methods include chemotherapy and percutaneous treatment of liver hydatidosis. MATERIAL AND METHODS The study was conducted at Sher-i-Kashmir Institute of Medical Sciences, Soura, Srinagar, Kashmir, India, over a period of two years from March 2001 to February 2003 with further follow-up of 5-6 years. The study included 64 cases in the age group of 15 years to 64 years, comprising 36 males and 28 females. The aim of the study was to know the effect of preoperative and postoperative albendazole therapy on the viability of protoscolices and recurrence rate of hydatid disease of liver. Patients were divided into four group of 16 each. In group A, patients were directly subjected to surgery. In group B, patients were given albendazole for 8 weeks followed by surgery. In group C, patients were given albendazole for 8 weeks preoperatively followed by further postoperative course for 8 weeks. In group D, patients were first taken for surgery followed by postoperative course of albendazole for 8 weeks. RESULTS Out of those patients who received preoperative albendazole only 9.37% had viable cysts at the time of surgery as compared to 96.87% of patients who did not receive any preoperative albendazole. In those patients who did not receive any albendazole therapy, recurrence rate was 18.75% whereas recurrence was 4.16% in patients who received albendazole therapy. CONCLUSION We conclude that albendazole is safe and effective adjuvant therapy in the treatment of hydatid liver disease.

Role of albendazole in the management of hydatid cyst liver

Background/Aim: Hydatidosis has a worldwide distribution and the liver is the most common organ involved. Hydatid cysts of the liver can be managed either by nonoperative or operative methods. Nonoperative methods include chemotherapy and percutaneous treatment. The study aimed at understanding the effect of albendazole therapy on the viability of protoscoleces and recurrence rate of hydatid disease of the liver. Patients and Methods: The study was conducted at Sher-i-Kashmir Institute of Medical Sciences, Soura, Srinagar, Kashmir, India, over a period of 2 years from January 2002 to December 2003, with further follow-up of 5 years. The study included 72 cases in the age group of 17-66 years, comprising 39 males and 33 females. The patients were randomized into two groups of 36 patients each. In group A, patients were directly subjected to surgery, while in group B, patients were administered albendazole for 12 weeks preoperatively, followed by a further postoperative course for 12 weeks. Results: Of patients who received albendazole therapy, no patient had viable cysts at the time of surgery, as compared to 94.45% of the patients who did not receive any preoperative albendazole (P<0.01). In patients who did not receive any albendazole therapy, recurrence rate was 16.66%, while no recurrence was seen in patients who received albendazole therapy (P≤0.05). Conclusion: We conclude that albendazole is an effective adjuvant therapy in the treatment of hydatid liver disease.

Atypical Localizations of Hydatid Disease: Experience from a Single Institute

Introduction: The hydatid disease most often involves the liver and the lungs. The disease can involve any part of the body except the hair, teeth and nails. Primary extrahepatico-pulmonary hydatid cysts are rare and only a few sporadic cases have been reported. Materials and Methods: Two hundred and forty-four patients with hydatid cysts managed surgically from January 2005 to December 2009 were evaluated retrospectively. Fourteen (5.7%) patients had isolated involvement of the atypical sites, while six (2.4%) also had a primary involvement of liver. Results: The cysts were present in gall bladder (0.4%), peritoneum (1.6%), spleen (1.6%), ovary (0.4%), subcutaneous (0.8%), seminal vesicle (0.4%), spinal (0.4%), pancreas (0.4%), kidney (0.4%), mediastinal (0.4%), muscle (0.4%), and brain (0.8%). Discussion and Conclusions: Involvement of sites other than liver and lungs by hydatid disease is rare. Symptoms are related to size, location or possible complication of the cyst. It should be strongly suspected in differential diagnosis of all abdominal cysts especially in an endemic area. Proper surgical and medical management to avoid any recurrences, and a regular follow-up, are of utmost importance to detect any late complications such as local recurrence of the disease and development of hydatidosis at the primary sites.

Disaster management of civilian gunshot head wounds in north Indian state

Abstract Management of 3794 gunshot wounds of head at disaster scale, who presented to our emergency room in groups continuously over a period of 20 years, by the Department of Neurosurgery at Sher-I-Kashmir Institute of Medical Sciences (SKIMS) Kashmir, India, from September 1988 to November 2008, revealed an overall mortality of 87.69% (3327 out of 3794). Patients were triaged in emergency CT-room. Most of the victims were males. Most of the deaths 79.14% (2633 out of 3327) occurred within 30 minutes of the patients arrival to the hospital and only 694 patients lived beyond one hour of arrival. Out Of total (3327) deaths, 2844 patients had admission GCS score of 3 and all of these died. No deaths occurred in the group of patients with GCS score 9-15. Poor and delayed mode of transportation accounted for 89.2% (2133 out of 2391) deaths. Elderly patients above 41 years of age in both sexes had poor outcome. 45 Children (below 18 years) were injured with a mortality of 42.2% (19 out of 45), attributing 0.57% (19 out of 3327) to total deaths. Surgical mortality was 30.9% (181 out of 585) and un-operative patients had 42.2% (46 out of 109) mortality. About 65.87% (276 out of 419) patients with admission-GCS score 4 to 8 were surgically salvageable. Predictors of poor outcome were low admission GCS score, fixed and dilated pupils, poor and delayed mode of transportation, hemodynamic instability, abnormal breathing at admission, coagulopathy and disseminated intravascular coagulation (DIC), CT visualisation of subarachnoid hemorrhage (SAH), ventricular hemorrhage, midline shift, bihemispheric and multilobar injuries and scalp wounds at occipital, temporal and frontal areas. However retained missile and bone fragments were less harmful than retained wooden (pulped mulberry stem) and cardboard wads and pneumocephalus in causing infections, cortical atrophy and seizures in the long run.

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.

Vertex epidural hematoma with bilateral abducent nerve palsy: case report and literature review.

Epidural hematomas which are located at the vertex are rarely seen and form a small percentage of total epidural hematomas. Tearing in the superior sagittal sinus is the usual cause of an epidural hematoma located in the vertex. The clinical features of this entity are non-specific; hence, localization of the lesion is difficult. We report an adult who was hit by a motorcycle and was initially discharged from the hospital as a case of concussional head injury. He returned back with raised intracranial pressure symptoms, so a CT scan was done but was misinterpreted, and he reported one week later with bilateral abducent nerve palsy. Magnetic resonance imaging confirmed vertex EDH for which he was operated.These hematomas are seen rarely and can be interpreted as an artifact. Its recognition is important because it has an excellent prognosis. We concluded that all head injury patients should get high axial cuts on the CT scan, and any degree of suspicion should prompt a neurosurgeon to investigate further with coronal CT scan or MRI.

Non-metallic and metallic craniocerebral missile injuries: Varied outcome

Abstract We studied the comparative outcome related to 694 non-metallic and metallic craniocerebral missile injuries who lived at 2 hours and beyond the time of injury in a retrospective and prospective analysis in the Department of Neurosurgery at Sher-I-Kashmir Institute of Medical Sciences (SKIMS) Kashmir, India, over a period of 21 years from September 1988 to March, 2010. The study revealed an overall mortality of 32.70% (227 out of 694). A total of 664 adults and 30 children (mostly teenagers) were studied. The 79.1% (549 out of 694) patients were metallic missile injuries whereas 20.8% (145 out of 694) patients were non-metallic missile injuries. The non-metallic missile injury group mostly (72.4% i.e.; 105 out of 145) had low GCS score and overall worse prognosis with zero good-recovery, 47.5% disabilities and 52.4% mortality as compared to the metallic missile injury group. The non-metallic group comprised of 60% (18 out of 30) children with one death. Non-metallic missile injuries accounted for 10.95% (76 out of 694 patients) of total deaths. Predictors of poor outcome were low admission GCS score, non-metallic penetrating injury due to tear-gas cartridges, rubber bullets and stone-bullets, perforating metallic missile injuries and delayed and maltransportation. Most complications in non-metallic missile injuries were infective and had poor outcome. The common non-metallic missiles used were stone bullets (balls) fired by Gulail (modified catapult) or slingshot, red rubber bullets, plastic tear gas shells and cartridges, wooden (pulped mulberry stem) and card-board wads used in shotguns. The stone pelting, throwing stone projectiles (stone-bullets) by Gulail and manually has become a common way to inflict head injuries in Kashmir. The non-metallic missiles are not less-lethal and have high disabling, killing and infective potential.

Dural-stabs after wide craniectomy to decompress acute subdural hematoma with severe traumatic brain edema — An alternative technique to open dural flap

Abstract The Department of Neurosurgery Sher-i-Kashmir Institute of Medical Sciences (SKIMS) Srinagar, a single neurosurgical centre in Kashmir valley, assessed prospectively, under a uniform protocol, 120 patients of severe traumatic brain edema with acute subdural hematoma by wide decompressive craniectomy with dural-stabs in 60(cases) patients as against conventional dural opening (open dural flap) and removal of acute subdural hematoma in 60(controls) patients during a period of 3 years (June 2006 to June 2009). A free bone flap was elevated and preserved. All patients had GCS (Glassgow Coma Scale) score of 8 and less. The elective ventilation and ICP monitoring was carried out in all patients. Most patients were young and males with a mean age of 30 years in both groups. The overall survival of the dural-stab group (case-study) was 78.3% with good recovery in 43.3% and a mortality of 21.6% (13/60) as compared to 40% survival in open dural flap (control) group with 11.6% good recovery and a mortality of 60% (36/60). The conventional (open dural flap) procedure to remove the clot proved dangerous in a traumatic “vent-searching” and edematous brain, restricted in a rigid cranial vault. This midway-approach, known in SKIMS as “dural-stabs”, between the only decompressive craniectomy and removal of acute subdural clot by open dural flap (conventional) method, proved much effective in increasing survival of low GCS and severe traumatic brain edema with acute subdural hematoma. In conclusion decompressive craniectomy alone is not sufficient and open dural flap is full of risk in such patients.

Gluteal pseudophallus in a male child: A rare cutaneous marker of occult spinal dysraphism

Congenital midline paraspinal cutaneous markers have been practically linked to the location and nature of neural-tissue lesions. One of the most interesting congenital midline paraspinal cutaneous markers has been the human tail in the lumbosacral region, with underlying spinal dysraphism. Human tails have many shapes and sizes and are usually localized to the lumbosacral region. After a complete neurological examination, the MRI is the most sensitive diagnostic modality to reveal the underlying occult spinal dysraphic state. Surgical excision is aimed at untethering of the spinal cord in symptomatic children and for aesthetic reasons in asymptomatic patients. Here we report an asymptomatic male child with normal external genitilia, whose tail is attached to the gluteal region like an adult phallus and investigations revealed an underlying spinal dysraphic state.