The Surgical Results in Pure Endoscopic Endonasal Trans-sphenoidal Surgeries in 403 Pituitary Adenomas: An 8-Years of Experience from a Single Neurosurgical Unit

Objective:  To review and report the results in pure endoscopic endonasal trans-sphenoidal surgery done at our unit for pituitary adenomas (PAs) in last 8 years. Material and Methods:  We reviewed 403 consecutive patients who underwent pure endoscopic endonasal trans-sphenoidal surgery for newly diagnosed pituitary adenomas between August 2012 and July 2020 at our neurosurgical unit. Endocrinological, demographic features and outcomes, their complications, and duration of stay in hospital were assessed in these patients who were operated in our neurosurgical Unit. The Mean Follow-up on average was 3.5 months. Results:  403 consecutive cases were reviewed. Majority of cases were in the 4th decade of life at presentation. 227 (56%) were non-functioning pituitary tumors and 176 (44%) were hormone secreting pituitary adenomas. Thirty-one (7.7%) complications were observed in 28 post-operative patients. The most frequently observed complication was diabetes insipidus (temporary in 19 (5%) and permanent in 3 (0.7%) cases), cerebrospinal fluids leaks (5 cases) (5.7%), Syndrome of inappropriate antidiuretic hormone (1 case) (0.2%), internal carotid injury (1 case) (0.2%), Empty Sella syndrome (1) (0.2%) and post-operative cardiac complication (1 case) (0.2%). The Follow-up on average was 3.5 months. Conclusions:  The pure endoscopic endonasal trans-sphenoidal surgery of pituitary adenomas provides acceptable and reasonable results representing a safe alternative procedure to the traditional Trans-sphenoidal microscopic approach

Frequency and Progression of Gliomas in Pregnancy in Population Presenting at Lahore General Hospital, Pakistan

Objective:  To study the frequency and progression of gliomas in pregnant patients in our population. Materials and Methods:  A retrospective study of 30 pregnant patients between 18 to 40 years of age with confirmed gliomas from July 2015 to July 2020 was conducted at the Department of Neurosurgery, Punjab Institute of Neurosciences, Lahore. Time of diagnosis, grade of glioma, the outcome of pregnancy, and mode of treatment were studied in these patients. Results:  Out of 30 patients, 29 were freshly diagnosed during pregnancy. All patients underwent cesarean section. If the patient presented before 30 weeks of pregnancy, irrespective of the outcome of the baby, the caesarian section was done. If a patient presented after 7 months, in case of low-grade glioma, the patient was in-house transferred and operated for tumor after delivery. A total of 17 patients had low-grade glioma and 12 patients had high-grade glioma. One patient had a recurrent disease during pregnancy, with the progression of tumor from low grade to high grade. Conclusion:  There is an association between pregnancy and the incidence of gliomas. They can be both high or low grades. The mode of delivery is preferably the caesarian section because the stress of labor causes an increase in the frequency of seizures. There is the possibility of recurrence as well as progression to higher grade during pregnancy

Outcome of Deep Brain Stimulation (DBS) for the Treatment of Parkinson’s Disease in Terms of Improvement in MDS-UPDRS Scale Over 5 Years

Background & Objective:  Parkinson’s disease (PD) is the second most common Neurodegenerative disorder after Alzheimer’s disease. There are several surgical procedures for advanced PD, but amongst all deep brain stimulation has proven to be safest and effective. The objective of this study was to see the outcome of DBS for the treatment of PD in terms of improvement in MDS UPDRS over 5 years. Material and Methods:  44 patients were included in study from Oct 2014 to Sep 2019. History, examination was carried out, and preoperative MDS-UPDRS (Movement Disorder Society Unified Parkinson’s Disease Rating Scale) was recorded. Postoperative improvement in MDS-UPDRS score was assessed at first Programming, 2nd week, and 6th week and at 3rd month. Results:  At baseline the mean, the MDS – UPDRS (Part-I) score was 14.20 ± 0.61 and at the end of 3rd month, the mean score was 11.18 ± 0.47 respectively. At baseline the mean, the MDS – UPDRS (part-II) score was 18.99 ± 0.70 and at the end of 3rd month, the mean score was 13.01 ± 0.57, respectively. At baseline the mean, the MDS – UPDRS (part-III) score was 45.19 ± 0.90 and at the end of 3rd month, the mean score was 25.15 ± 1.20 respectively. At baseline the mean, the MDS – UPDRS (part-IV) score was 10.18 ± 0.87 and at the end of 3rd month, the mean score was 3.85 ± 1.03, respectively.  Conclusion:  The Deep Brain Stimulation (DBS) is safe and effective in the management of PD

Clinical Outcome of Percutaneous Radiofrequency Rhizotomy for Trigeminal Neuralgia at a Tertiary Care Hospital.

Background: - Trigeminal neuralgia is a disease typically characterized by involuntary attacks of lancinating pain in the distribution of the trigeminal nerve that are activated by non-noxious stimuli. Numerous anticonvulsants, either alone or in combination, remain the first choice in the medical treatment of trigeminal neuralgia.3If the disease becomes non responsive, there are numerous surgical options like micro vascular decompression or minimally invasive percutaneous lesioning of the trigeminal nerve, such as glycerol rhizolysis, Radiofrequency Rhizotomy, and balloon compression. Objective: - To determine efficacy of percutaneous Radiofrequency Rhizotomy for trigeminal neuralgia in terms of early pain relief in a tertiary care hospital. Methods: -  62 patients with refractory trigeminal neuralgia or lancinating, recurrent episodes of pain in the distribution of Ophthalmic (V1) and Mandibular (V3) branches of trigeminal nerve, not responsive to 6 months of conservative treatment were included. Study was completed in one year i.e. from March 2015 to Feb 2016. Result: - In our study population, 62 included patients were had mean age 56.08 ± 7.39 years. 44 patients (71%) were male. Our treatment was effective in 58 patients (93.5%) while there was recurrence among 4 (6.5%) only. Conclusion: - It is concluded that the efficacy of percutaneous Radiofrequency Rhizotomy for trigeminal neuralgia in terms of complete relief of pain with intact sensations in treated branch region is excellent (93.5%)

Pallidotomy: Effective and Safe in Relieving Parkinson’s Disease Rigidity

Introduction: Parkinson's Disease (PD) is a progressive neurological disorder caused by a loss of pigmented dopaminergic neurons of the substantia nigra pars compacta. The major manifestations of the disease consist of resting tremor, rigidity, bradykinesia and gait disturbances. Before the advent of Levodopa surgery was main stay of treatment of PD. Medical therapy is still the mainstay of treatment for Parkinson's diseasebut its prolonged use results in side effects like drug induced dyskinesia. In 1952 Dr. Lars Leksell introduced Pallidotomy that was successful in relieving many Parkinsonian symptoms in patients. Later on thalamotomy became widely accepted, replacing pallidotomy as the surgical treatment of choice for Parkinson's Disease. Thalamotomy had an excellent effect on the tremor, was not quite as effective at reducing rigidity rather bradykinesia was often aggravated by the procedure.Objective: Effectiveness of Pallidotomy in rigidity in medically refractory Parkinson’s disease and its complications.Study Design: Descriptive prospective case series.Setting of study: Department of Neurosurgery, Lahore General Hospital, Lahore.Duration: June 2013 to April 2016.Materials and Methods: Patients of Parkinson’s disease with predominant component of muscular rigidity despite maximum medical therapy admitted through outdoor department. Detailed history and physical exami-nation was done. Grading of muscular rigidity was done by applying UPDRS score Rigidity part 22. Secondary Parkinsonism was ruled out with the help of CT scan and MRI brain. Surgery was performed after informed consent.Results: Twenty patients were included in the study with no lost to follow up. There were 14 (70%) male and 6 (30%) female patients. Mean age of the patients was 47.58 ± 8.69 years. There were 11 (55%) left sided procedures and 9 (45%) right sided Pallidotomy procedures performed. Mean pre-operative rigidity using UPRDS was 24.9 ± 1.47, while post-operative score was 11.87 ± 1.53. Pallidotomy procedure in our study had no mortality but 4 (20%) patients suffered from procedure related complications one patient (5%) had transient hemiparesis, 1 (5%) suffered from wound infection, 1 (5%) having dysarthria and 1 (5%) transient diplopia.Conclusion: Pallidotomy is effective as well as safe surgical treatment option in reducing rigidity for medically refractory Parkinsonism’s Disease

Anterior Cervical Discectomy and Fusion: Operative Technique and Post-Operative Complications – An Experience in a Tertiary Care Hospital

Background and Objective: The most common spinal procedure in our set up to address various disorders of the cervical spine like prolapsed intervertebral disc, trauma, and degenerative disc disease is an anterior cervical discectomy and fusion (ACDF). As there is no technique without complication, this procedure is also related with certain important complications. We evaluated post-operative complications of ACDF in our institution.Material and Methods: The preoperative data of 148 patients who were operated in last 3 years for ACDF isincluded in the study. Patients with previous neck surgery are excluded.Results: The most commonly performed surgical interventions is single level ACDF (65%). Dysphagia is mostsignificant (16%) complication. After which neurological deterioration (9%) with equal incidence of RecurrentLaryngeal Nerve Palsy and wound infection that is 8% each.Conclusion: The most common post-operative complications are dysphagia and worsening of preexistingneurology and multilevel ACDF is identified as the most common risk factor. Early recognition of complicationsand management may help to reduce mortality and morbidity

Outcome of Endoscopic Repair of CSF Rhinorrhea with Endonasal Endoscopic Approach in terms of Success of Repair.

Objective: This descriptive case series conducted to evaluate the outcome of CSF rhinorrhea repair with the Endonasal Endoscopic approach in terms of success of the repair.Materials and Methods: The study was conducted at Neurosurgery department, Unit II, Punjab institute of neurosciences, Lahore. This study involved 40 patients aged between 3-80 years of both genders diagnosed of CSF rhinorrhea with presented with in 1 week after trauma and spontaneous and postoperative cases.Results: The age of the patients ranged from 5 years to 53 years with a mean of 22.75 ± 15.59 years. Total 30 (75%) male and 10 (25%) female patients are included in the study. The underlying etiology was found to be post-traumatic (67.5%) 27 cases, followed by post-operative in 7 (17.5%) and spontaneous in 6 (15.0%) cases. Successful repair was observed in 36 (90.0%). No significant difference was found in the frequency of successful repair among various age groups; 5-20, 21-36 and 37-53 years (95.7%, 83.3% and 81.8%; p = 0.381), gender groups; male verses female (86.2% and 100.0%; p = 0.194) and etiological groups; post-traumatic vs. post-operative vs. spontaneous (92.6% vs. 71.4% vs. 100.0%; p = 0.169).Conclusions: The frequency of successful repair was found to be 90% in patients of CSF rhinorrhea treated through Endonasal endoscopic approach. No statistically significant difference was found in successful repair frequency across patient’s gender, age and underlying cause of CSF rhinorrhea

Cabergoline: an effective treatment for conception in prolactinoma

Background and objective: Prolactinoma is an uncommon cause of amenorrhea and subfertility in females. When diagnosed, symptoms resolve with medical treatment in 90% of the cases. Conception and uneventful pregnancy, however, remain a big challenge in these patients. The objective of this study was to determine the therapeutic effectiveness of Cabergoline for conception in female patients with prolactinoma. The duration for restoration of menstruation, spontaneous conception, and outcomes of pregnancy were recorded over a period of 1 year in relation to prolactin level estimation.Methods: This prospective study was carried over a period of 2 years from December, 2019 to December, 2021. A total of 696 female patients of reproductive age, diagnosed with prolactinomas, were included and randomly divided into 2 groups; A (Cabergoline) and B (Bromocriptine), and were given standard doses of both drugs. The duration for restoration of menstruation, spontaneous conception, and outcomes of pregnancy were recorded over a period of 1 year in relation to the serum prolactin level estimations.Results: Most of the females were 25-30 years of age and most of them (98.2%) presented with amenorrhea. Restoration of menstruation was found to be earlier in group A, i.e., 3.6 months, as compared to group B, i.e., 5.8 months. Spontaneous conception within 6 months was observed in 42.6% of the patients of group A as compared to group B (26.8%). The rate of miscarriage was comparable in both groups. The live birth rate in the Cabergoline and Bromocriptine groups was 84% and 73.4%, respectively (p = 0.02). Mode of delivery was Caesarean section in both groups in all participants. Serum prolactin levels were significantly reduced in the Cabergoline group as compared to the Bromocriptine group (p = 0.035).Conclusion: Cabergoline is an effective drug for spontaneous conception within 6 months of successful restoration of menstruation in female patients with prolactinomas. Live birth rate is also higher in the Cabergoline group as compared to the Bromocriptine group.&nbsp;</p

The Outcome of Prolactinoma in the Postpartum Period: a Study from a Tertiary Care Hospital in Pakistan: a study from a tertiary care hospital in Pakistan

Objective:  Prolactin is an essential hormone secreted by the pituitary gland of pregnant women. The pituitary gland undergoes growth, due to lactotroph hyperplasia in response to placental estrogen during pregnancy. Research on the postpartum outcomes of prolactinomas is less. This study evaluates the prevalence of Prolactinoma and the occurrence of spontaneous resolution of Prolactinomas after pregnancy. Materials and Methods:  A cross-section study was conducted at the Punjab Institute of Neurosciences, Lahore. 200 pregnant women were recruited; their blood samples were collected to evaluate serum prolactin levels. Women diagnosed with prolactinomas exhibiting positive symptoms were given dopamine agonists. The administration of dopamine agonist was discontinued at the 24th week of gestation. All participants were monitored till birth, at 40 days after delivery, and throughout breastfeeding. Their prolactin levels were evaluated, and magnetic resonance imaging (MRI) was conducted to verify the resolution of prolactinoma. Results:  The mean age of females in the study was 29.03 ± 7.20 years. Out of 200, 40 (20%) females had prolactinoma. Out of 40, 13 (32.5%) were given Bromocriptine while 27 (67.5%) were given Cabergoline. At presentation, the mean serum prolactin level was 138.91 ± 149.02 ng/ml, which reduced to 21.38 ± 9.80 ng/ml. The mean tumor size at presentation was 7.23 ± 2.07 mm, which reduced to 0.79 ± 0.66 mm after delivery. Out of 40, 30 (75.0%) had spontaneous resolution. Conclusion:  The occurrence of prolactinoma is low in symptomatic patients and can resolve spontaneously after delivery in the majority of cases

SARS-CoV-2 vaccination modelling for safe surgery to save lives: data from an international prospective cohort study

Background: Preoperative SARS-CoV-2 vaccination could support safer elective surgery. Vaccine numbers are limited so this study aimed to inform their prioritization by modelling. Methods: The primary outcome was the number needed to vaccinate (NNV) to prevent one COVID-19-related death in 1 year. NNVs were based on postoperative SARS-CoV-2 rates and mortality in an international cohort study (surgical patients), and community SARS-CoV-2 incidence and case fatality data (general population). NNV estimates were stratified by age (18-49, 50-69, 70 or more years) and type of surgery. Best- and worst-case scenarios were used to describe uncertainty. Results: NNVs were more favourable in surgical patients than the general population. The most favourable NNVs were in patients aged 70 years or more needing cancer surgery (351; best case 196, worst case 816) or non-cancer surgery (733; best case 407, worst case 1664). Both exceeded the NNV in the general population (1840; best case 1196, worst case 3066). NNVs for surgical patients remained favourable at a range of SARS-CoV-2 incidence rates in sensitivity analysis modelling. Globally, prioritizing preoperative vaccination of patients needing elective surgery ahead of the general population could prevent an additional 58 687 (best case 115 007, worst case 20 177) COVID-19-related deaths in 1 year. Conclusion: As global roll out of SARS-CoV-2 vaccination proceeds, patients needing elective surgery should be prioritized ahead of the general population