Sandeep Mohindra

Rhinocerebral mucormycosis: the disease spectrum in 27 patients

The variable forms of clinical complaints, findings and time interval of presentation in 27 cases of mucormycosis have been described, which were encountered over a span of 8 years. The previous concept about this fungal infection attacking chronic, debilitated, immunocompromised patients does not appear to hold true. Seven of the 27 patients (22.2%) did not reveal any predisposing factors and their outcome of 42.9% survival seems to be poorer than the total outcome (66.7%). ‘Chronic form’ of disease presentation, the definition of which is still not delineated, was encountered in four patients (14.8%). Again, the outcome was not significantly different from the total survival. Burr‐hole tap of an intracranial abscess revealing mucor in a 2‐month‐old infant has been described. Even in the present era, extranasal exenteration of sinuses along with disfiguring orbital exenteration is required to ensure satisfactory surgical debridement. Control of the underlying predisposing illness, along with the aggressive surgical debridement and the parenteral administration of amphotericin B, remains the treatment essentials even today.

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.

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.

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.

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.

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.

Cervicobulbar intramedullary lipoma

BACKGROUND CONTEXT Spinal lipomas not associated with spinal dysraphism are rare entities. Further, large medullary lipomas with intracranial extension are occasionally described. Most of the intradural lipomas are subpial and not really intramedullary. PURPOSE Clinicians may be made aware of such a rare entity and its presentation. STUDY DESIGN/SETTING An extremely rare case of medullary lipoma extending into posterior fossa is described in an adult, not associated with spinal dysraphism. METHODS A young male presented with high cord myelopathy in the form of spastic quadriparesis. Radiological investigations revealed dorsally placed intramedullary lipoma extending into posterior fossa. RESULTS Surgical excision of tumor provided satisfactory resolution of symptoms. CONCLUSIONS Medullary lipomas may present with features of high cord compression and myelopathy. Magnetic resonance imaging remains the investigative and follow-up modality of choice. Even when total tumor excision is not feasible, subtotal removal and decompression provides long lasting symptom-free survival.

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.