Upendra Prasad Devkota

Hyponatremia in Patients with Traumatic Brain Injury: Etiology, Incidence, and Severity Correlation

BACKGROUND Hyponatremia is common in patients with traumatic brain injury (TBI). This study aims at ascertaining the incidence of hyponatremia in TBI with its etiologic diagnosis, biochemical confirmation, and severity correlation with initial Glasgow Coma Scale (GCS) score and computed tomography (CT) abnormality. METHODS All patients more than 20 years old with severe and moderate TBI and the mild ones with CT abnormality were included. Daily sodium level was monitored for 14 days. Central venous pressure (CVP) was measured for assessment of volume status. Fractional excretion of uric acid (FEUA) was measured in all patients with hyponatremia, both before and after its correction. RESULTS Of 40 consecutive patients, 33 remained for analysis. Hyponatremia was seen in 9 (27.2%) patients, of whom 6 developed it within the first week. Mean duration of hyponatremia was 1.78 days. We found that 5 patients had an elevated CVP consistent with the syndrome of inappropriate antidiuretic hormone (SIADH), whereas 3 had low CVP consistent with cerebral salt wasting syndrome (CSWS) and 1 had an equivocal reading. Measurement of FEUA did not show consistent pattern to suggest a biochemical distinction. There were 33.3% each of mild and moderate, and 16.6% of severe TBI among hyponatremic patients. Hyponatremia was seen in Rotterdam CT scores I to IV in increasing incidence (r = 0.983, P = 0.017), whereas it had no significant correlation with initial GCS (r = 0.756, P = 0.455). CONCLUSIONS Hyponatremia due to SIADH is more common in TBI. FEUA measurement is not consistent enough to make a distinction between SIADH and CSWS. CT scoring of severity is more predictive of hyponatremia than initial GCS.

β-Lactamase-Producing Multidrug-Resistant Bacterial Pathogens from Tracheal Aspirates of Intensive Care Unit Patients at National Institute of Neurological and Allied Sciences, Nepal

The widespread use of tracheal intubation and mechanical ventilation to support the critically ill patients increases the risk of development of tracheobronchitis and bronchopneumonia. This cross-sectional study was conducted with an aim to isolate and identify bacterial pathogens from tracheal aspirates producing extended-spectrum β-lactamase (ESBL), AmpC β-lactamase, and metallo-β-lactamase (MBL) from August 2011 to April 2012 at National Institute of Neurological and Allied Sciences (NINAS), Kathmandu, Nepal. ESBL was detected by combined disk assay using cefotaxime and cefotaxime with clavulanate, AmpC β-lactamase by inhibitor-based method using cefoxitin and phenylboronic acid, and MBL by Imipenem-EDTA combined disk method. 167 bacterial strains were isolated from 187 samples and majority of them were Acinetobacter spp. followed by Klebsiella pneumoniae with 32.9% and 25.1%, respectively. 68.8% of isolates were multidrug resistant (MDR) and Acinetobacter spp. constituted 85.4%. ESBL, AmpC β-lactamase, and MBL were detected in 35 (25%), 51 (37.2%), and 11 (36.7%) isolates, respectively. Pseudomonas spp. (42.8%) were the predominant ESBL producer while Acinetobacter spp. were the major AmpC β-lactamase producer (43.1%) and MBL producer (54.5%).

Superior sagittal sinus thrombosis presenting as a continuous headache: a case report and review of the literature

Cerebral venous sinus thrombosis is a rare but dangerous condition, occurring with an incidence of 3-4 cases/million/year. Cerebral venous sinus thrombosis presents a diagnostic challenge due to its varied presentation patterns. We report a case of a 42 year old Nepali man diagnosed with cerebral venous sinus thrombosis after presenting with a week long history of continuous headache. He improved rapidly following prompt anticoagulation. Despite thorough investigation no discernable underlying cause could be found. Our report highlights the value of prompt diagnosis of cerebral venous sinus thrombosis through neuroimaging and the importance of immediate anticoagulation as part of patient management.

Chorea-acanthocytosis: a case report

Neuroacanthocytosis is a group of rare disorders. We report a 36-year-old right-handed female who presented with gradually progressive abnormal facial movements, generalized weakness, and lower-lip biting starting 4 years ago. On examination, she had lower-lip ulcer, orofacial dyskinesias, and peripheral neuropathy. Her peripheral blood smears showed acanthocytosis and magnetic resonance imaging revealed atrophied head of caudate nuclei and putaminal hyperintensities on T2-weighted and fluid attenuated inversion recovery images. Work-up for autoimmune and metabolic causes was negative. She was diagnosed with chorea-acanthocytosis, an entity under neuroacanthocytosis syndrome and the patient was offered symptomatic treatment.

Nosocomial Isolates and Their Drug Resistant Pattern in ICU Patients at National Institute of Neurological and Allied Sciences, Nepal.

Multidrug resistant organisms are increasing day by day and the cause is poorly known. This study was carried out from June 2011 to May 2012 at National Institute of Neurological and Allied Sciences Kathmandu, Nepal, with a view to determining drug resistant pathogens along with detection of extended spectrum β-lactamase (ESBL), AmpC β-lactamase (ABL), and metallo-β-lactamase (MBL) producing bacteria causing infection to ICU patients. A standard methodology was used to achieve these objectives as per recommendation of American Society for Microbiology. ESBL was detected by combined disc assay using cefotaxime and cefotaxime clavulanic acid, ABL by inhibitor based method using cefoxitin and phenylboronic acid, and MBL by imipenem-EDTA combined disk method. Two hundred and ninety-four different clinical samples such as tracheal aspirates, urine, pus, swabs, catheter tips, and blood were processed during the study. Most common bacteria were Acinetobacter spp. Of the total 58 Acinetobacter spp., 46 (79%) were MDR, and 27% were positive for ABL and 12% were for MBL. Of the 32 cases of Staphylococcus aureus, 18 (56%) were MDR. Findings of this study warrant routine β-lactamase testing in clinical isolates.

Predictors of Unfavourable Seizure Outcome in Patients with Epilepsy in Nepal

BACKGROUND Despite optimal medical therapy, a sizeable number of patients continue to have persistent seizures. We evaluated the association of pretreatment and treatment variables with unfavorable seizure outcome. METHODS Patients with follow-up over 12 years in the Nepal Epilepsy Association were evaluated. Patients having seizures for at least a year and already on polytherapy after failure of two monotherapy trials were considered having unfavourable outcome. Variables under study were: age, sex, duration and frequency of seizures prior to treatment, type of seizure, neurological status, Computed Tomography (CT) finding, and failure of first anti-epileptic drug (AED). Bivariate analysis was done with Chi-square and Fisher exact tests. Potential interaction between variables was studied with a logistic regression analysis. RESULTS Out of a total 529 consecutive patients, 490 were included in the study. Unfavorable seizure outcome was seen in 26.8% of patients. Among 284 patients who remained viable for analysis, bivariate analysis showed significant association of unfavorable outcome with frequency of seizure (p 0.01), abnormal neurological status (p 0.01) and failure of first AED (p 0.00), while no significant association was seen with age at onset (p 0.45), sex (p 0.47), duration of seizure (p 0.43), type of seizure (p 0.12), and presence of CT abnormality (p 0.46). The fitted regression model portended an unfavorable prognosis with failure of first AED and abnormal neurological status, however, failed to show significant association with frequency of seizure. CONCLUSIONS Failure of first AED trial and associated neurological deficits are significant predictors of unfavorable seizure outcome.

Contributing Factors for Coagulopathy in Traumatic Brain Injury.

Context: In traumatic brain injury patients, coagulation disorder causes secondary brain injury, thereby increasing mortality and morbidity. Aims: The aim of this study is to identify the factors responsible for coagulopathy in traumatic brain injury. Settings and Design: This prospective longitudinal study from June 2012 included 100 patients with moderate and severe head injury presenting to National Institute of Neurological and Allied Sciences, Kathmandu, over 1-year period. Subjects and Methods: Patients were evaluated for the development of coagulopathy, defined as collectively three abnormal hemostatic parameters, and associated risk factors for coagulopathy. They were then analyzed for correlation with coagulopathy. Statistical Analysis Used: SPSS version 16 was used for the analysis of data. For identification of contributing factors, a stepwise logistic regression analysis was performed, including the factors with P < 0.05 from the analysis. Results: Among the 100 patients, coagulopathy was present in 63% of cohort. Forty-three patients had severe head injury, and 76.7% (n = 33) of them had coagulopathy compared to 52.7% (n = 30) in 57 patients with moderate head injury (P = 0.013). Statistically significant correlation with coagulopathy was present with polytrauma, severity of head injury, blood transfusion, surgical intervention, and Marshalls classification of CT of the head; however, stepwise logistic regression analysis showed that blood transfusion, surgical intervention, polytrauma, and severity of head injury were significant independent variables responsible for the development of coagulopathy. Conclusions: Traumatic brain injury is complicated with coagulopathy in up to 63% of patients. Blood transfusion, surgical intervention, polytrauma, and severity of head injury are significant independent variables responsible for coagulopathy.

Outcome Difference in Neurosurgical Patients Based on Timing of Tracheostomy and Ventilator Associated Pneumonia

Tracheostomy is a very common procedure in neurosurgical ICU patients. In order to improve the respiratory dynamics and for the ease and effi ciency of chest physiotherapy, patients with depressed level of consciousness who cannot be extubated early are considered for tracheostomy. In addition to that, complications of prolonged orotracheal intubation also Outcome Difference in Neurosurgical Patients Based on Timing of Tracheostomy and Ventilator Associated Pneumonia Pratyush Shrestha MS, MCh Neurosurgeon

Excision of an anterior intradural arachnoid cyst of the cervical spine through central corpectomy approach

Anterior cervical intradural arachnoid cyst is a rare entity which has been mostly approached posteriorly, commonly resulting in incomplete resection. Incomplete resection is associated with recurrence; hence, we describe the anterior central corpectomy approach with complete neurologic recovery in a twenty year old with an anterior cervical intradural arachnoid cyst in front of the third and fourth cervical vertebra, who had presented with spastic quadriparesis.

Feasibility and efficacy of thrombolysis in acute ischemic stroke: A study from National Institute of Neurological and Allied Sciences, Kathmandu, Nepal

Background: Stroke is the major cause of morbidity and mortality worldwide. The number of stroke patients receiving recombinant tissue plasminogen activator (rt-PA), also known as Alteplase, in the developing world is extremely low. We aim to study the feasibility and efficacy of thrombolysis for the 1st time in our country. Materials and Methods: In this retrospective study (July 2012-August 2015), acute ischemic stroke patients who were thrombolyzed within 3 h of stroke onset were included. Their demographic profiles, clinical profiles, risk factors, type of thrombolytic used, and outcomes were systematically recorded and analyzed. Results: A total of 9 patients were thrombolyzed. The mean time from the onset of stroke symptoms to first dose of rt-PA (onset to treatment) was 1.2 h. Six patients had good neurological outcome as measured by modified Rankin Scale (mRS). The median mRS at discharge was 3. Thrombolysis-related post treatment complication was noted in 44.4%, of which nonfatal intracranial bleed occurred only in 2 patients (22.2%). None of the patients receiving intravenous tenecteplase had thrombolysis-related complications, and none of the patients had fatal intracranial bleed. Conclusion: This study clearly demonstrates the beginning of a feasible and effective thrombolysis in the treatment of acute ischemic stroke in Nepal.