Shibu Pillai

Prognostic factors in children with severe diffuse brain injuries: a study of 74 patients.

Severe diffuse brain injury in children has a devastating influence on their physical and psychological development. This retrospective study was undertaken to analyse the factors that influence outcome in children with such injuries. The short-term outcomes (Glasgow outcome score) of 74 children (age ≤15 years) with severe diffuse brain injury and no focal operable mass lesions on CT scan, admitted between 1992 and 1998 at the National Institute of Mental Health and Neurosciences were analysed. The prognostic factors analysed were age, gender, time after injury to admission, nature of injury, highest post-resuscitation Glasgow coma score (GCS), pupillary reaction, horizontal oculocephalic reflex and CT scan findings. The following factors were found to be independent predictors of poor outcome: GCS 3–5 (p < 0.003), absent verbal response (p < 0.001), motor response score of 1–3 (p < 0.001), absent pupillary reaction (p < 0.001), absent oculocephalic reflex (p < 0.001) and presence of traumatic subarachnoid haemorrhage on CT scan (p < 0.002). These independent variables were then subjected to a stepwise logistic regression analysis, and the most important variables for predicting outcome were oculocephalic reflex and GCS, which together correctly predicted unfavourable outcome with a sensitivity of 79% and a specificity of 65%. An early CT scan or a single CT scan did not have any prognostic significance.

Reduced contribution of executive functions in impaired working memory performance in mild traumatic brain injury patients.

AIM Mild traumatic brain injury (MTBI) is associated with often selective impairment of both working memory (WM) and the executive functions (EFs). Research indicates that one of the commonest deficits present in MTBI patients falls in the domain of WM. We aimed to investigate the role of EFs in WM impairment following MTBI. METHODS Performance on the tests of EFs and the verbal and visuo-spatial WM of 30 consecutive MTBI patients were compared with age/education/IQ matched 30 normal healthy control participants. Correlation between EFs and WM was studied separately for the MTBI and the control group. RESULTS The MTBI and control group were tested on a range of EF tests and WM. The MTBI group was demonstrated impairment on verbal and visuo-spatial WM and category fluency tests only. Furthermore, the MTBI group had fewer significant correlations between the WM and EFs (5 out of 54 possible correlations) than in the control group (13 out of 54 possible correlations). CONCLUSIONS We suggest that MTBI may lead to WM deficits as the contribution of executive processes to support the WM is diminished following MTBI. Such an understanding of the poor WM performance in MTBI patients will be helpful when planning appropriate strategies for cognitive rehabilitation.

Post-concussion syndrome: Correlation of neuropsychological deficits, structural lesions on magnetic resonance imaging and symptoms.

BACKGROUND Post-concussion syndrome (PCS) associated with mild traumatic brain injury (MTBI) can cause long-lasting disabilities. Magnetic resonance imaging (MRI) evaluation in these patients may demonstrate structural lesions that correlate with functional deficits on neuropsychological testing. However, little is known about the significance of the relationship between structural lesions on MRI, functional deficits on neuropsychological evaluation and outcome in patients with MTBI. AIMS To assess neuropsychological deficits and structural lesions on MRI in patients with PCS following MTBI, and to find correlation between these findings and PCS. SETTINGS AND DESIGN Prospective, observational, cohort study in a tertiary hospital. MATERIALS AND METHODS The study cohort included consecutive patients with MTBI (three months or more duration) and PCS. All the patients in the cohort had neuropsychological testing using the National Institute of Mental Health and Neurological Sciences Neuropsychological Battery for head injury and also MRI using T1, T2 and FLAIR sequences. Statistical analysis was done using Fishers Exact test of significance. RESULTS All the 20 patients evaluated had neuropsychological deficits. Eleven patients had lesions on MRI. Disturbances of sleep, behavior and memory and abnormalities in tests for mental speed were more frequent in patients with lesions on MRI, but were not statically significant (P = 0.08). Both the test modalities localized lesions predominantly to the frontal and temporal lobes. All the symptoms observed in the patients were associated with prefrontal dysfunction on neuropsychological testing. CONCLUSIONS Prefrontal dysfunction is invariably associated with PCS following MTBI. Structural lesions on MRI may not always be present but when present may influence the degree or severity of the symptoms.

Cerebellar abscesses in children: excision or aspiration?

OBJECT Cerebellar abscesses are common neurosurgical emergencies in developing countries, and have a distressingly high mortality rate of 10 to 15% even today. There is still no consensus on the standard approach to these lesions, and controversy persists over whether these lesions should be treated with primary excision or aspiration. METHODS The authors retrospectively analyzed 82 cases of cerebellar pyogenic abscesses in children treated at their institution over a period of 10 years. This represents the largest such series being described in literature. All lesions except 1 were otogenic in origin. The clinical and radiological features are discussed. RESULTS Primary excision was undertaken in 66 patients (80%) and aspiration in 16 patients (20%). Five patients in whom the abscesses were initially treated with aspiration subsequently underwent elective excision. Nine (12.6%) of 71 patients in whom the abscesses were excised had residual abscesses on postoperative imaging; in those who had undergone aspiration as the primary treatment, 6 (54.5%) of 11 patients had recurrent abscesses. There were no deaths among the patients who underwent excision of the abscess. Also, excision of posterior fossa abscesses required fewer repeated procedures with lower recurrence rates, and statistically lower rate of complications. CONCLUSIONS Compared to primary aspiration, the authors found that primary excision is the preferred method for treating cerebellar abscesses.

Successful treatment of tremor in Wilson's disease by thalamotomy: A case report

Little information is available on the surgical treatment of movement disorders in Wilsons disease. We report a successful outcome of left‐sided stereotactic thalamotomy in a 30‐year‐old man with Wilsons disease, who had severe postural‐kinetic tremor of both hands. The improvement was bilateral. Our case illustrates that stereotactic thalamotomy may be considered as an option in treating severe tremor in selected patients of Wilsons disease and merit further trials.

Sensory gating impairment in development of post‐concussive symptoms in mild head injury

Abstract  Post‐concussive symptoms reported by mild head injury (MHI) patients have been inadequately understood. Post‐concussive symptoms reported by patients with MHI have so far been explained in terms of impairment in neurocognitive functions or deficits in modulation of flow of information. There are no studies that have looked into sensory gating impairment in MHI and its relation to post‐concussive symptoms. The purpose of the present paper was to investigate the role of sensory gating impairment in post‐concussive symptoms in mild head injury patients. Thirty MHI patients were evaluated for their neuropsychological functions, sensory gating deficits, and post‐concussive symptoms. Neuropsychological functions were in the domain of attention, executive functions, and learning and memory. Sensory gating was assessed by Structured Interview for Assessing Perceptual Anomalies and post‐concussive symptoms were assessed using the Neurobehavioral Rating Scale. Multiple regression method was used to identify predictors for post‐concussive symptoms. Post‐concussive symptoms were predicted by sensory gating deficits when sensory gating deficit was one of the predictors along with neuropsychological functions. Post‐concussive symptoms were predicted by scores of Digit Vigilance and Digit Symbol Substitution Test, when predictors were restricted to neuropsychological functions. Sensory gating deficits were correlated with performance on Digit Symbol Substitution test. Post‐concussive symptoms reported by MHI patients are the result of poor modulation of incoming sensory information.

Role of citicoline in the management of mild head injury

Abstract Mild head injuries can cause functional disabilities resulting in economic loss. Post concussion syndrome is seen in 15–45% of these patients. Cytidine-5′-diphosphocholine (citicoline) is known to improve cognitive dysfunction. This study was undertaken to evaluate the effect of citicoline on the number of working days lost and on post concussion symptoms following mild head injury in adults, in a randomized, prospective, single blind study. Following informed consent, adults with mild head injury (Glasgow coma score of 13–15,

Intensive care management of head injury patients without routine intracranial pressure monitoring.

BACKGROUND Head injury contributes significantly to mortality and morbidity in India. Evaluation of the available trauma care facilities may help improve outcome. AIM To evaluate the factors influencing the mortality of patients with head injury who had intensive care management and evolve strategies to improve outcome. SETTING AND DESIGN Retrospective study in a tertiary hospital where intracranial pressure monitoring (ICPM) is not routinely practiced. MATERIALS AND METHODS All patients with head injury managed in the intensive care unit in a two-year period were included. The factors evaluated were age, vital signs, Glasgow Coma scale score (GCS) at admission, pupillary light reflex (PR), oculocephalic reflex (OCR), hemodynamic stability, computerized tomography (CT) findings, diabetes mellitus, anemia, infections and abnormalities of serum sodium. RESULTS We analyzed 208 patients (202 without ICPM). In-hospital mortality was 64 (31%). Only 24 (11.5%) patients were admitted within one hour of injury, while one-third arrived after six hours. The clinical factors (at admission) that influenced mortality included age, GCS, PR, OCR and diastolic blood pressure (DBP). Effacement of the basal cisterns in the initial and repeat CT scans, hyperglycemia, hemodynamic instability and serum sodium imbalances were associated with higher mortality. The independent predictors of mortality by logistic regression were initial GCS, DBP, hemodynamic instability and effacement of cisterns on repeat CT. CONCLUSIONS Mortality following head injury is high. Pre-hospital emergency medical services are disorganized. The key to reducing mortality within the limitations of our current trauma system is maintenance of DBP>70 mmHg and SBP>90 mmHg from the time of first contact.

Home based cognitive retraining in traumatic brain injury

Abstract Traumatic brain injury is a complex injury with a broad spectrum of symptoms and disabilities. The impact on a person and his or her family can be devastating. Cognitive difficulties are very common in people with traumatic brain injury. Studies have shown neuropsychological rehabilitation to be usefulness in improving the cognitive functions and day-to-day functioning. The purpose of the study was to examine the efficacy of home based cognitive retraining in traumatic brain injury. Single case-study was adopted. The neuropsychological profile of the patient was compared pre and post home based cognitive retraining. A 32-year-old male was referred for post head-injury neuropsychological assessment and rehabilitation. He was given 6 months package of home based cognitive retraining. The training was given by patient’s wife. The preassessment showed impairment in frontal and temporal functions. Results indicated improvement in cognitive functions, occupational functions and social functioning.

Unilateral Moyamoya Phenomenon Due to MCA Occlusion in a Child Presenting with Intracerebral Hemorrhage

A cerebrospinal fluid fistula consists of an abnormal leaking of cerebrospinal fluid from the subarachnoidal space through defects in the dura and pia -arachnoid. Its major problem is not the leaking by itself but the open communication thus established between subarachnoidal and extra-arachnoidal spaces, leading to repeated bouts of meningitis• The main causes are traumatic but there are several other conditions known to produce CSF leaking. Surgery is usually the treatment required for these leaks. Neuroradiological studies are required in this condition to localise the fistula site, document ventricular size and rule out associated fractures, congenital anomalies, space-occupying lesions and osteomyelitis.