Comparison of Frequency of Recurrence after Burr Hole Evacuation of Chronic Subdural Hematoma with or without Subdural Drain.

Chronic subdural hematoma (CSDH) is known to have a significant recurrence rate. The rate of recurrence of chronic subdural hematoma after surgery ranges from roughly 5% to 30%.  Burr hole evacuation without drainage is performed as a first line of treatment for CSDH. As there is controversy in literature regarding the use of drainage after burr hole evacuation, the results of my study may be helpful for selecting a proper treatment modality as a first line of treatment for CSDH in terms of recurrence. The objective of this study was to compare the frequency of recurrence after burr hole evacuation of CSDH with and without subdural drain. It was a randomized controlled trial conducted in Department of Neurosurgery, Allied hospital, Faisalabad form Aug 2016 to Aug 2018 RESULTS:In our study, out of 130 cases(65 in each group). 84.62%(n=55) in Group-A and 76.92%(n=50) in Group-B were between above 40 years of age whereas 15.38%(n=10) in Group-A and 23.08%(n=15) were between 18-40 years of age, mean+sd was calculated as  64.03+7.61 years in Group-A and 62.28+7.83 years in Group-B, 78.46%(n=51) in Group-A and 72.31%(n=47) in Group-B were male while 21.54%(n=14) in Group-A and 27.69%(n=18) in Group-B were females, comparison of frequency of recurrence after burr hole evacuation of CSDH with and without subdural drain shows 10.77%(n=7) in Group-A and 27.69%(n=18) in Group-B, p value was 0.01 showing a significant difference. CONCLUSION: We concluded that the frequency of recurrence after burrhole evacuation of CSDH is significantly lower with drain when compared without subdural drain

Impact of Bronchoscopic Lavage and Aggressive Chest Physiotherapy on Clinical Pulmonary Infection Score of Patients of Severe Traumatic Brain Injury

Introduction:  Traumatic brain injury patients present in the emergency room with a variable conscious status depending upon the severity of the injury. The process of aspiration starts from the scene of trauma as the patients with Traumatic brain injury and chest trauma have higher rates of aspiration pneumonia. Materials and Methods:  We conducted a prospective study to assess the impact of bronchoscopy lavage and aggressive chest physiotherapy on the Critical Pulmonary Infection Score of Patients with Severe Traumatic Brain Injury in the Neurocritical Care Unit. Patients with severe traumatic brain injury who met the inclusion criteria were enrolled in the study. Patients of both genders, ages ranging from 05 – 70 years were included in the study. Results:  48 patients who met the inclusion criteria were enrolled in the study. 8 patients expired before 7 days and were excluded from the study. 88% were male and 12 % were females. Out of 40 patients, 30 were ventilated and 10 were managed without ventilation. Brain contusion was the most common CT scan finding. Out of 40 patients, 18 underwent surgical intervention, with decompressive hemicraniectomy being the most commonly performed procedure. Out of 40 patients, 32 patients underwent bronchoscopy. 8 patients out of 32 had more than two sessions of bronchoscopy. Conclusion:  As Critical Pulmonary Infection Score is an important indicator for pneumonia in the neurocritical care unit, the importance of standardized chest care with the help of bronchoscopic lavage and chest physiotherapy in keeping the Critical Pulmonary Infection Score on the lower side can prevent patients from developing life-threatening pneumonia

Microscopic Discectomy Outcomes in Lumbar Disc Herniation Patients

Background: Radiculopathy due to herniated lumbar disc is one of the most common determinant of sciatica. Most patients with sciatica respond well to non-surgical treatment. Surgery is performed when there is an established neurological deficit or when conservative management is not successful in achieving positive results in pain.Objective: To evaluate the frequency of good outcomes regarding pain relief after lumbar microscopic discectomy in adult patients presenting with radiculopathy.Material and Methods: Current study includes 80 patients, both male and female between 20-70 years and admitted for herniated lumbar disc surgery. Microscopic discectomy was performed in all these patients. Outcome variable was frequency of good outcome in terms of post-operative pain ? 4/10. Informed consent in written was obtained from the individual patient.Results: In 73 (91.3%) cases good outcome was observed. No substantial difference was noticed in the frequency of good outcome according to the duration of herniated disc (p = 0.960), pre-operative pain score (p = 0.499), age (p = 0.851) and gender (p = 0.703).Conclusion: Good outcome was observed in 91.3% patients presenting with herniated lumbar disc undergoing microscopic discectomy regardless of patient’s age, gender, pre-operative pain and duration of disc herniation

PMMA cranioplasty making by using open-source CAD software, PLA printers, and silicone rubber molds: technical note with two illustrative cases

No abstract available

Role of intraoperative computed tomography scanner in modern neurosurgery – An early experience

Background: Intraoperative imaging addresses the limitations of frameless neuronavigation systems by providing real-time image updates. With the advent of new multidetector intraoperative computed tomography (CT), soft tissue can be visualized far better than before. We report the early departmental experience of our intraoperative CT scanner’s use in a wide range of technically challenging neurosurgical cases. Methods: We retrospectively analyzed the data of all patients in whom intraoperative CT scanner was utilized. Out of 31 patients, 24 (77.4%) were cranial and 8 (22.6%) spinal cases. There were 13 male (41.9%) and 18 (58.1%) female patients, age ranged from 1 to 83 years with a mean age of 34.29 years ±17.54 years. Seven patients underwent spinal surgery, 2 cases were of orbital tumors, and 16 intra-axial brain tumors, including 5 low- grade gliomas, 10 high-grade gliomas, and 1 colloid cyst. There were four sellar lesions and two multiloculated hydrocephalus. Results: The intraoperative CT scan guided us to correct screw placement and was crucial in managing four complex spinal instabilities. In intracranial lesions, 59% of cases were benefitted due to intraoperative CT scan. It helped in the precise placement of ventricular catheter in multiloculated hydrocephalus and external ventricular drain for a third ventricular colloid cyst. Conclusion: Intraoperative CT scan is safe and logistically and financially advantageous. It provides versatile benefits allowing for safe and maximal surgery, requiring minimum changes to an existing neurosurgical setup. Intraoperative CT scan provides clinical benefit in technically difficult cases and has a smooth workflow

Lipid-Based Nano-Formulation Development to Enhance Oral Bioavailability of Weakly Aqueous-Soluble Drug for Obesity and Hypertension

The most practical method of drug delivery is oral administration because it has a high rate of patient compliance. However, there are significant obstacles to effective oral medication delivery, including low drug enzymatic/metabolic stability and poor water solubility. Especially in the development of drug formulations for the treatment of obesity and hypertension. This research article aims to formulate solid lipid nanoparticles (SLN) of Fucoxanthin and Ramipril by the emulsification and ultrasonication methods. The nanoparticles size, polydispersity index, and the zeta potential, among other parameters, were computed. In addition, FT-IR analysis of compatibility tests between the SLNs and the loaded drug and in vitro drug release experiments were carried out. Lipid-based nano preparations have drawn plenty of interest as efficient vehicles to increase the oral bioavailability of these kinds of medications. We observed that lipid nanoparticles, have enhanced the oral bioavailability of poorly water-soluble drugs used for obesity and hypertension. Provided the above information, formulated SLNs should be further investigated using cutting-edge scientific methodologies to improve its bioavailability

Prognostic Factors for Decompressive Hemicraniectomy in Severe Traumatic Brain Injury Patients with Traumatic Mass Lesions: A Prospective Experience from a Developing Country

Objective:  To evaluate the prognostic factors affecting functional clinical outcomes in severe traumatic brain injury patients with traumatic mass lesions undergoing decompressive hemicraniectomy (DHC). Materials and Methods:  A prospective cohort of 85 patients of severe traumatic brain injury patients with traumatic mass lesions underwent a unilateral decompressive hemicraniectomy. Functional outcomes were assessed using the Glasgow Outcome Score at 28 days, 3 months, and 6 months. Bivariate analysis (chi-squared) was used to identify parameters that resulted in poor outcomes and multiple regression was used to identify independent factors predicting poor outcomes. Results:  85 patients were recruited. Functional outcomes were dichotomised as favourable (Glasgow Outcome Score of 4 – 5) and poor (Glasgow Outcome Score 1-3) and evaluated at 28 days, 3 and 6 months. A total of 59 patients expired (69.4%). Bivariate analysis revealed GCS 3 – 5 at presentation (P = 0.002), midline shift greater than 7.5mm (P < 0.001), the volume of the mass lesion more than 40ml (P = 0.006) resulted in a poor outcome. Age dichotomised to less than or more than 50 years bordered statistical significance (P = 0.063). Only GCS at presentation and midline shift were independent factors that predicted poor outcomes when controlling for covariates.  Conclusion:  Decompressive hemicraniectomy can be a lifesaving intervention in managing severe traumatic brain injury patients with traumatic mass lesions. However, its use needs to be employed judiciously.&nbsp

Lhermitte-Duclos Disease: a rare cerebellar hamartoma presenting following traumatic brain injury and a review of the literature

Lhermitte-Duclos Disease (LDD) is an extremely rare hamartoma of the cerebellum and is associated with the cancer syndrome Cowden’s disease. We report such a patient whose disease was diagnosed incidental to traumatic brain injury. A 40-year-old male presented after fall from stairs. CT scan revealed a large lesion in the right cerebellar hemisphere. Clinical history recounted multiple short episodes of vomiting (>10 a week) for the past 30 years and development of posterior fossa symptoms over the recent months. Neither of these had him referred due to lack of access to primary healthcare. T1 MRI with contrast showed an isointense focal mass, enhancement along the folia, and distortion of the 4th ventricle. On T2 MRI, tiger striped appearance was noted. Endoscopic third ventriculostomy was performed followed by gross total resection of the hamartoma. Histology confirmed LDD. All reported symptoms resolved following surgery. Due to lack of access to the expensive genetic testing for Cowden’s he is in regular biannual follow up to be evaluated clinically for associated malignancies. We present this case to highlight the clinical-pathological characteristics of LDD, its treatment, and discuss management in the absence of genetic testing in our socio-economic demographic

Early experience with patient-specific low-cost 3D-printed polymethylmethacrylate cranioplasty implants in a lower-middle-income-country: Technical note and economic analysis

Background: Polymethyl methacrylate (PMMA) cranioplasty, while widely prevalent, has limitations associated with freehand manual intraoperative molding. PMMA has been superseded by titanium or Polyetheretherketone implants, prefabricated commercially from preoperative CT scans, and boasting superior clinical and cosmetic outcomes. However, such services are extremely inaccessible and unaffordable in the lower-middle-income country (LMIC) settings. The study aims to describe, in detail, the process of making ultra-low-cost patient-specific PMMA cranioplasty implants with minimum resources using open-access software. We report the first such service from the public health-care system within Pakistan, a LMIC. Methods: Using open-source software, preoperative CT heads were used to prefabricate three-dimensional implants. Both implant and cranial defects were printed using polylactic acid (PLA) to assess the implant’s size and fit preoperatively. From the PLA implant, we fashioned a silicon mold that shapes the PMMA implant. Ten patients who underwent cranioplasty using our technique for various cranial defects with at least a 12-month follow-up were retrospectively reviewed. Clinical, cosmetic, and radiological outcomes were objectively assessed. Results: Etiology of injury was trauma (8), malignant MCA infarct (1), and arteriovenous fistula (1). We produced seven frontotemporal-parietal implants, one bifrontal, one frontal, and one frontoparietal. At 1 year, eight patients reported their cosmetic appearance comparable to before the defect. Radiological outcome was classified as “excellent” for eight patients. No postoperative complications were encountered, nor did any implant have to be removed. One patient’s implant involving the orbital ridge had an unsatisfactory cosmetic outcome and required revision surgery. The average cost per implant to the National Health Service was US$40. Conclusion: Prefabricated patient-specific PMMA cranioplasty implants are cost-effective. A single surgeon can fashion them in a limited resource setting and provide personalized medicine with excellent clinical/cosmetic-radiological results. Our method produces patient-specific cranioplasty implants in an otherwise unaffordable LMIC setting

Prospective elective neurosurgical theater utilization audit in Pakistan: problems in a public tertiary care hospital and proposed solutions from lower-middle-income country

Background: In lower-middle-income countries such as Pakistan, public hospitals provide free healthcare but suffer from poor management and misgovernance, negatively impacting service provision. One aspect of this is operating theater time (OTT) utilization. In a 1,600-bed hospital with a 22 million catchment population, we noticed significant delays and inadequate OTT efficiency at the neurosurgery department of Jinnah Hospital, Lahore, Punjab, Pakistan. This audit aimed to analyze the neurosurgical OTT utilization, identify delays, and highlight managerial deficiencies and areas for improvement while comparing our workflow with contemporary international literature. Materials and Methods: We prospectively audited OTT utilization at the neurosurgical department. All elective surgeries from January to April 2021 were included to identify delays concerning patient transfer, anesthesia team arrival, preparation and intubation time, operative time, and anesthesia extubation time. Results: Fifty-six per cent of OTT was utilized operating. Sources of delay included the delayed arrival of anesthesia team (4.7%) and the delay in transferring patients to OT (9.7%). Anesthesia intubation and preparation time accounted for 23% of OT utilization and was significantly longer than the comparable international studies. Extubation time accounted for 5.7% of OT utilization. The issues surrounding transfer delays and prolonged anesthesia time were discussed, with strategies to address them developed with close vital input from our anesthesia colleagues and ward staff. Conclusion: Gross delays relatively simple in nature were identified due to poor management and less than ideal interspecialty coordination. Most delays were avoidable and can be addressed by proper planning, optimization of patient transfer and resources, and, most importantly, improved communication between surgeons, anesthetists, and ward staff. This can ensure optimal use of theater time and benefit all specialties, including ancillary staff, and, most importantly, the patient. A reaudit is warranted to assess the impact of interventions on OTT utilization