Vijendra K. Jain

Intracranial aneurysms in patients 18 years of age or under, are they different from aneurysms in adult population?

SummaryBackground. Intracranial aneurysms are extremely uncommon in the first two decades of life. This study was undertaken to assess the clinicoradiological features and surgical outcome of intracranial aneurysms in patients less than or equal to 18 years of age; and, to highlight the differences between these and intracranial aneurysms seen in adult patients.Methods and material. Twenty-two patients, 18 years of age or under (male:female ratio=1.75:1; mean age 14.18±3.8 years, age range 5 to 18 years) and 451 adult patients aged older than 18 years (male:female ratio=1:1.05; mean age 48.21±12.71 years, age range, 19 to 81 years) were treated for intracranial aneurysms at our center between January 1991 and July 2003. The univariate statistical analysis was used to compare differences between the two groups.Findings. The patients under 18 years constituted 4.6% of the total patient population having intracranial aneurysms. The incidence of associated medical diseases was greater in patients under 18 years than in the adults (9% versus 0.26%, p<0.05). The incidence of seizures was more than double in patients under 18 years (36% versus 17%, p<0.05). The incidence of intracerebral haematoma (ICH; 41% versus 22.5%, p>0.05), intraventricular haemorrhage (IVH; 45% versus 34%, p>0.05), and hydrocephalus (36% versus 25%, p>0.05) were higher in patients under 18 years. In adult patients, anterior communicating artery (AcoA) and in children, ICA bifurcation were the most frequent sites of aneurysm formation respectively (p<0.05). The incidence of giant aneurysms was nearly double in children (13.6% versus 6.5%, p>0.05). The incidence of clinical vasospasm was almost the same in both groups. The overall outcome was favourable in 82% of patients under 18 years and 58.8% in adults. The management mortality in patients under 18 years was 9.1%, while in the adult patients, it was 19%.Conclusion. In patients under 18 years of age, there was a definite male predominance; a higher incidence of seizures; and, the ICA bifurcation formed the most frequent site of intracranial aneurysms. In adults, AcoA a was the commonest site. Rebleeding and delayed ischaemic deficits were the major causes of morbidity. Favorable outcome after surgery in young patients was better in comparison to their adult counterparts.

Effect of spinal cord signal intensity changes on clinical outcome after surgery for cervical spondylotic myelopathy

OBJECT The presence of intramedullary T2 high signal intensity changes in patients with cervical spondylotic myelopathy (CSM) indicates the existence of a chronic spinal cord compressive lesion. However, the prognostic significance of signal intensity changes remains controversial. The purpose of this study was to evaluate the effect of spinal cord T2 signal intensity changes on the outcome after surgery for CSM. METHOD In a prospective study, 64 patients with CSM who underwent surgical treatment between October 2006 and April 2008 using an anterior approach were included. Based on the clinical symptoms and signs present, the severity of neurological deficits of all patients was scored according to a modified Japanese Orthopaedic Association scale score for CSM just before the surgery and at 6 months follow-up. Recovery rates were calculated at 6 months. RESULTS There were 22 patients who did not have spinal cord intensity changes on MR imaging and 44 who demonstrated high-intensity signal changes on T2-weighted images (focal or segmental). No statistically significant differences were found in recovery rates between cases with T2 signal intensity changes and those with no signal intensity changes. However, the postoperative modified Japanese Orthopaedic Association scale scores and the recovery rates were much lower in patients with multisegmental signal intensity changes compared with those without these changes or those with focal signal intensity change, and ANOVA demonstrated this difference to be statistically significant (p < 0.05). CONCLUSION Multisegmental spinal cord signal intensity changes on T2-weighted MR imaging are predictors of a poor outcome in terms of functional recovery rate in patients undergoing operations for CSM.

Intrinsic third ventricular craniopharyngiomas: report on six cases and a review of the literature

BACKGROUND Craniopharyngiomas constitute 2 to 4% of intracranial neoplasms. However, the purely intraventricular variety are rare. Their magnetic resonance imaging (MRI) characteristically shows an intact third ventricular floor, a patent suprasellar cistern, an intact pituitary stalk, and the absence of sellar abnormalities. METHODS Between 1994 and June 2002, 6 patients with purely intraventricular craniopharyngioma were surgically managed. There were 4 cystic and 2 solid lesions. The surgical approaches utilized included a frontal, parasagittal, transcallosal approach with the third ventricle being accessed using either the transforaminal or subchoroidal approach (n = 3); pterional, transsylvian (n = 1), and bifrontal interhemispheric (n = 2) approaches in which the third ventricle was accessed via the lamina terminalis. A ventriculoperitoneal shunt was required for one of the 3 patients with hydrocephalus. RESULTS Total excision was performed in 3 patients with cystic craniopharyngioma, while a small residual lesion was left adherent to the third ventricular floor in the others. There was one perioperative mortality because of septicemia. Two patients required thyroxine supplementation. Two patients developed transient and one other patient a sustained diabetes insipidus. The 2 patients with solid tumors received radiotherapy for the residual lesions. At follow up ranging from 8 to 36 months, neither tumor recurrence nor regrowth was observed in any of the patients. The symptoms of raised intracranial pressure, hypothalamic dysfunction or visual field defects had resolved. CONCLUSIONS Intraventricular craniopharyngiomas occur in an older population and present mainly with raised intracranial pressure. Visual and endocrinologic imbalances are much less in these lesions compared to the suprasellar craniopharyngiomas. They mainly attach to the third ventricular floor. The surgical approaches to the third ventricle, along with radiotherapy and hormone supplementation, were successful in the management of these rare tumors.

Thoracic myelopathy secondary to ossified ligamentum flavum.

Summary.Summary.Background: Focal ossification of the ligamentum flavum (OLF) forms one of the rare causes of thoracic myelopathy. The lower thoracic spine is most frequently affected and the patients present with initial posterior column disturbances followed by progressively increasing spastic paraparesis. The pathogenesis of OLF has not been conclusively established.Method: Five patients with thoracic myelopathy due to OLF underwent decompressive laminectomy and excision of the ligamentum flavum. Their MRI delineated a linear or beak like excrescence, uniformly hypo-intense on T1 and T2 weighted images, situated posterior to the thecal sac. A comparison between the pre-operative neurological status and the status at follow-up was done using Harshs myelopathic grading.Finding: Decompressive laminectomy followed by the drilling of the OLF and its excision, occasionally along with the adherent outer layer of the dura, resulted in significant improvement in motor weakness and tingling sensations. However, at the last available follow-up, none of the patients had retained their ability to run briskly (grade I) and all of them had residual spasticity.Interpretation: OLF may significantly contribute to a spatial reduction of the thoracic spinal canal resulting in paraparesis. The T2 weighted sagittal image of the magnetic resonance imaging (MRI) is the modality of choice for screening of the longitudinal extent of the OLF. A rapid neurological improvement occurs following decompressive laminectomy and excision of the OLF. However, the persistence of residual spasticity at follow-up may be due to irreversible changes within the cord by the significant thecal compression and the delay between the onset of initial symptoms and signs and surgical decompression.

Intraventricular meningiomas: A surgical challenge

BACKGROUND Primary intraventricular meningiomas (IVM) pose a surgical challenge as they often remain asymptomatic until they become very large; have close proximity to vital intraventricular structures; and, their vascular supply is often encountered only after significant tumor debulking. In this study, the surgical management of IVM is discussed. METHODS Between 1989 and 2003, nine patients (7 with lateral and 2 with fourth ventricular) IVM, were operated upon. Raised intracranial pressure, gait ataxia, memory impairment, seizures (motor and sensory) were the main presentations. Four had hydrocephalus while five had either a sequestered temporal or occipital horn. All were large tumors with an average size more than 5.3 cm. The lateral ventricular IVM were accessed by the posterior middle temporal gyrus (n=5) or the superior parietal lobule (n=2) approach. A midline suboccipital craniectomy was used for the fourth ventricular IVM. RESULTS Total excision was achieved in eight and partial excision in one. Patients with lateral ventricular tumors required a postoperative intraventricular drain for a minimum period of 48 hours. The main morbidity included visual field defects and transient hemiparesis, seizure and meningitis. The one patient with partial excision died 6 weeks later due to transtentorial herniation as a result of intratumoral bleed and lateral ventricular sequestration. CONCLUSIONS An IVM, being initially asymptomatic, usually attains a large size before detection. During surgery, its devascularisation is usually achieved only after significant tumor debulking. Development of hydrocephalus or ventricular sequestration should be constantly monitored and may be avoided in the postoperative period by continuous external ventricular drainage.

Surgical Management of Remote, Isolated Type II Odontoid Fractures with Atlantoaxial Dislocation Causing Cervical Compressive Myelopathy

OBJECTIVE:The remote (more than 6 mo after injury) and isolated (not associated with any other cervical spinal fractures) Type II fractures of the odontoid (RI IIO) are unique in being inherently unstable and prone to malunion or nonunion, leading to cervical compressive myelopathy. The present study discusses their surgical management. METHODS:Nineteen patients with RI IIO with atlantoaxial dislocation (AAD) causing compressive myelopathy were treated. Their preoperative disability was graded as Grade I: neurologically intact (presented with hyperreflexia and mild spasticity; n = 3); Grade II: independent with minor disability (n = 7); Grade III: partially dependent for daily needs (n = 6); and Grade IV: totally dependent (n = 3). They were classified as irreducible AAD caused by 1) malunited fracture of the odontoid (n = 2), 2) fixed anterolisthesis of the anterior arch of a C1-fractured odontoid complex (n = 3), and 3) fixed retrolisthesis of the anterior arch of a C1-fractured odontoid complex (n = 1); and reducible AAD caused by 1) mobile AAD (n = 11) and 2) hypermobile AAD (n = 2). The patients with irreducible AAD underwent a transoral decompression and posterior fusion; those with a malunited fracture underwent surgery immediately, whereas those with fixed anterolisthesis or retrolisthesis were initially placed in cervical traction. The patients with reducible AAD underwent a direct posterior fusion. In the patient with “hypermobile” AAD, a proper alignment of the fractured segment of the odontoid relative to the body of the axis in a neutral position of the neck was ensured before the posterior fusion was performed. RESULTS:At follow-up (mean, 15.37 ± 9.67 mo), three patients in Grade I maintained their neurological status. Of the seven patients in Grade II and six in Grade III, five had improved to Grade I, and eight were in Grade II. The three patients in Grade IV improved to Grade I, II, and III, respectively. CONCLUSION:The patients with RI IIO may be divided into five groups on the basis of their differing management protocols. There is a considerable risk of delayed myelopathy unless surgical reduction and stabilization are performed. Posterior stabilization is the preferred option in dealing with these fractures. Despite the presence of severe neurological deficits and the prolonged duration of symptoms, a significant neurological improvement usually occurs after surgery.

Multisegmental cervical ossification of the posterior longitudinal ligament: Anterior vs posterior approach

AIMS To determine the surgical approach in patients with multisegmental (four or more segments) OPLL of the cervical spine. METHODS AND MATERIALS Data of 27 patients who had undergone either an anterior (corpectomy with excision of OPLL and interbody fusion = 14 patients) or posterior approach (laminectomy = 12, laminoplasty = 1 patient) for the multisegmental cervical OPLL was analyzed retrospectively. The patients in each group were statistically similar in respect to preoperative factors such as age, duration of symptoms, preoperative modified Japanese orthopedic association score, OPLL thickness, effective canal diameter, and antero-posterior cord compression ratio. The clinical outcome was assessed by the Harsh grading system and recovery rate was assessed by Hirabayashi method. RESULTS There was no statistical difference in the outcome, and recovery rate. Nine patients developed complications after anterior approach in contrast to one after posterior approach. CONCLUSIONS In patients with multisegmental cervical OPLL, there was no significant difference in the short-term recovery rate and outcome between two groups. The immediate postoperative complications were less in patients who had undergone posterior approach. From our analysis, it appears that the posterior approach is probably the preferred method of treatment in a multisegmental OPLL in absence of preoperative kyphosis.

Pediatric Intracranial Aneurysms: An Institutional Experience

Introduction: Intracranial aneurysms are extremely uncommon in the pediatric population. Their epidemiology is poorly understood, and certain features make them unique. In our study we analyzed pediatric intracranial aneurysm patients to gain an insight into the epidemiology, clinicoradiological profile and outcome. Material and Methods: Out of 36 children (≤18 years of age; male:female ratio = 1.076:1; mean age 13.19 ± 3.72 years, age range 5–18 years) presenting with subarachnoid hemorrhage (SAH; n = 33; 91.67%) and mass effect (n = 3; 8.33%), 27 who were positive on digital subtraction angiography and treated for intracranial aneurysms between January 1991 and February 2007 were included in this study. Results: At presentation, the majority (n = 21) of the pediatric intracranial patients showed a good grade, and 23 (85.18%) presented with SAH. Sudden severe headache (n = 19; 70.37%) and loss of consciousness (n = 14; 51.85%) were the most common symptoms, and meningeal signs (n = 18; 66.66%) most commonly elicitable. There were 7 patients with giant aneurysms and 8 patients with posterior circulation aneurysms. Internal carotid artery (ICA) bifurcations (n = 6; 18.18%) followed by middle cerebral artery (MCA) bifurcations (n = 4; 12.12%) were the most common sites. At a mean follow-up of 18.67 ± 10.85 months (range 1–42 months), there were 21 (77.77%) patients with favorable outcome and 3 patients died. Conclusions: Intracranial aneurysms in children commonly present with SAH; there is a male predominance, and ICA bifurcations followed by MCA bifurcations are the most common sites. The incidence of posterior circulation aneurysms and giant aneurysms is higher as compared to adults. The pediatric patients present with better grades and have better overall surgical results.

Surgery of vestibular schwannomas: An institutional experience

AIMS To report management results of vestibular schwannomas (VS) treated surgically in our institute, with particular reference to completeness of tumor excision, facial nerve and hearing preservation and complications of surgery. STUDY DESIGN AND SETTINGS Retrospective study of 259 patients treated during the years 1988 to 2002. MATERIALS AND METHODS The facial nerve function and hearing assessment was done according to House-Brackmann [HB] grading and pure tone audiometry (PTA) respectively. All patients were operated by retro-mastoid sub-occipital approach. RESULTS Most patients had large tumors and had no useful hearing (90%), had disabling cerebellar ataxia (88%) and presented with features of raised intra-cranial pressure (45%). Large sized tumors were in 41.3% and giant sized tumors were in 56% cases. Complete tumor excision was carried out in 96.5% and anatomical preservation of facial nerve was achieved in 79.2% cases. Hearing preservation was achieved in 8 patients. Cerebrospinal fluid leak with or without meningitis and transient lower cranial nerve paresis were common complications. The mortality was 6%. CONCLUSIONS With experience, complete tumor excision with good facial nerve preservation can be achieved in large tumors. Hearing preservation is difficult in bigger tumors. Prevention and control of infection was a major concern.

Corpectomy for multi-level cervical spondylosis and ossification of the posterior longitudinal ligament

The choice of a surgical approach for multi-level cervical spondylotic myelopathy (CSM) and ossification of the posterior longitudinal ligament (OPLL) is still a controversial issue. While most of the surgeons are still performing decompression by laminectomy some are doing multi-level anterior decompression. Few neurosurgeons are performing decompression by corpectomy. We have treated 26 patients by median cervical corpectomy during the last 4 years. These patients were followed up for a mean period of 25 months. Twenty one (80%) patients had a good outcome, 2 patients remained unchanged and 3 expired. Review of the literature and our experience indicates that patients with CSM and OPLL should be operated by median cervical corpectomy (anterior approach).