Spectrum of Head Trauma at Tertiary Care Military Hospital CMH Quetta, Pakistan

Objective: The objective of this study was to determine the etiological spectrum, injury patterns and outcome of head injured patients at tertiary care military hospital CMH Quetta.Materials and Methods: This descriptive study includes all patients of head trauma coming to trauma centre at CMH Quetta, Pakistan. Patients with associated injuries of other organs were excluded from the study. We noted the detailed clinical history and examination, demographics, mechanism of injury, treatment offered (operative / non operative) and analyzed the details of operative procedure (craniotomy, craniectomy, elevation of compound depressed fracture, scalp suturing), morbidity and outcome (according to Glasgow outcome scale). Data was analyzed using SPSS version 16.Results: There were 1026 patients (856 males and 170 females) eligible to be included in the study. The mean age of the patient was 28.9 ± 19.2 years SD. Majority of the patients belonged to the age group 21 – 40 years. The commonest cause of head injury was Road traffic accident 507 (49.41%), fall 273 (26.6%), gunshot wound 97 (9.45%), bomb blast injury 76 (7.41%), sports related 35 (3.41%), mine blast 25 (2.44%) and splinter injury 13 (1.27%) of patients. CT Brain findings were contusions in 116 (11.3%), isolated fractures in 45 (4.38%), SDH in 44 (4.28%), EDH in 43 (4.19%), DAI (diffuse axonal injury) in 36 (3.51%), compound depressed fractures in 16 (1.55%), frontal sinus fractures in 14 (1.36%), combined EDH / SDH in 6 (0.58%) and normal CT brain findings in 706 (68.81%) patients. 662 (64.52%%) patients were managed conservatively and 364 (35.47%) underwent operative management. Major operations (craniotomy / craniectomy / elevation of compound depressed skull fracture) were performed in 138 (13.45%) and minor operations (suturing of scalp laceration) were performed in 226 (22.03%). Good recovery was seen in 894 (87.13%), moderate disability in 26 (2.53%) and severe disability in 12 (1.16%) whereas 16 (1.56 %) patients remained vegetative. The mortality was 78 (7.6%).Conclusion: In Pakistan, head injury contributes significantly to mortality and morbidity. Road traffic accident, history of fall and gunshot are the commonest causes of head injury. Appropriate medical care facilities needs to be established at district and tehsil level to provide prompt and adequate care to head injured patients

Management of Intracranial Hydatid Cyst

Objective: To know the clinical presentation and surgical complication of intracranial hydatid cyst.Materials and Methods: This retrospective study was done in neurosurgery department of Hayatabad Medical Complex, Peshawar, from 2nd February 1998 to 1st October 2012. A total of 37 patients with intracranial hydatid cyst, irrespective of gender discrimination were included in this study. Intracranial hydatid cyst was diagnosed on CT scan brain. The information regarding patient demographical details, clinical features, CT brain findings and post-operative complications was documented in patient’s Performa. The data was analyzed by SPSS version 16. Frequency and percentage was calculated for categorical variables. Mean ± SD was calculated for age. Results were presented as tables.Results: A total of 37 patients were included in the study. Out of 37 patients, there were 23 (62.8%) males and 14 (37.14%) females. The mean age was 12.4 years. Most of patients presented with increased intracranial pressure features like headache, vomiting and papilloedema. Majority of the patients had hydatid cyst in parietal region %. Post-operatively two patients having wound infection and no mortality.Conclusion: Hydatid disease should be kept in the differential diagnosis of cystic lesion of the brain. The pericystic hydraulic hydatid cyst excision is the safe procedure with minimal morbidity

Chronic Subdural Hematoma in Elderly Patients after Trivial Head Injury

Background: Chronic subdural hematoma is a benign disease but its behavior is more than a malignant space occupying lesion intra-cranially and it kills patient, if diagnosis delayed. Chronic subdural hematoma is frequently associated with underlying co-morbidities like diabetes mellitus, hypertension, ischemic heart diseases and atrial fibrillation in elderly patient. Early recognition of chronic subdural hematoma is important for early management.Objective: To identify the factors for causing chronic sub-dural haematoma following minor head injury.Materials and Methods: This observational descriptive study was conducted in the Department of Neurosurgery “A” Unit, Lady Reading Hospital Peshawar from 1st January 2016 to 31st July 2018. All patients with history of minor head injury resulting in unilateral or bilateral chronic subdural hematoma diagnosed clinically and radiologically by CT scan/MRI brain, Age greater than 60 years & operated for chronic subdural hematoma were included in this study. Exclusion criteria was all chronic subdural hematoma patients with age less than 60 years and previous operated. Medical records of patients were revised and searched for associated risk factors. A proforma was designed for collection of data. The data was analyzed through SPSS Version17.Results: Total number of patients were (46) with male to female ratio (3:1). Clinical presentations were decreased level of consciousness in 11 patients (23.9%), Headache in 10 patients (21.7%), Memory loss in 5 (10.8%), Personality changes in 10 patients (21.7%), Motor deficits in 5 patients (10.8%), Aphasia in 5 patients (10.8). The risk factors found were Diabetes Mellitus 8 cases (17%), Hypertension 16 cases (35%), Rheumatic heart disease 1 case (3%), Ischemic heart disease 15 cases (32%) and atrial fibrillation 6 cases (13%).Conclusion: The common risk factors for chronic subdural hematoma was ischemic heart disease, hypertension, diabetes mellitus and atrial fibrillation. Early management results in favorable prognosis in terms of morbidity and mortality

Outcome of Traumatic Posterior Fossa Epidural Hematomas

Objective: To present our experience in the management and outcome of posterior fossa epidural hematoma (PFEDH).Materials and Methods: It was a descriptive study, conducted in Head injury unit Hayatabad Medical Complex, Peshawar, from December 2009 to October 2012. All patients having traumatic posterior fossa extradural hematoma confirmed on CT Brain were included in this study. The information regarding patient demographical details, clinical presentation, operative finding and post operative follow-up findings were entered into a semi structure Performa. The data was analyzed by SPSS version 17.Results: Out of 41 patients, there were 32 (75.6%) males and 9 (21.9%) females. The age of patients ranged from 5 to 60 years. In this study the mean age was 20.4 years. Majority of patients 17 (41.4%) were in the age range of 21 – 30 years. Pre-operative GCS score were recorded in which most of the patients 21 (51.2%) were in the GCS score 13 – 15. Clinically 33 patients presented with vomiting, 25 with altered level of consciousness, and 29 with headache. Post-operative GCS score were recorded in which 31(75.6%) patients were in the GCS score 13 – 15, 9 (21.9%) patients were in the GCS score 9 – 12 and 1 (2.43%) patient was in the GCS score 3 – 8. Conclusion: CT scan brain should be immediately done if there is even little doubt of posterior fossa extra-dural haematoma (PFEDH). Posterior fossa creniectomy has got good results. Mortality and morbidity can be decreased in PFEDHs if they are diagnosed earlier and promptly treated

Frequency of Extra-dural Hematoma in Patients with Head Injury

Objectives: To determine the frequency of extra-dural hematoma in patients with head injury.Patients and Methods: This cross sectional descriptive study was done in neurosurgery department of Hayat-abad Medical Complex, Peshawar, from 2nd February 2012 to 1st September 2012. All patients of head injury, from all ages and both genders were included. Patients in whom EDH caused by bleeding disorders or vascular malformations of the dura mater and post surgical EDHs were excluded from the study. CT scan brain was done for all patients to confirm their diagnosis. The information regarding patient demographical details, clinical presentation and site and size of hematoma was documented in patient’s Performa. The data was analyzed by SPSS version 17.Results: A total of 281 patients with head injuries were included in the study. Out of 281 patients, there were 191 (67.9%) males and 90 (32.02%) females. The mean age was 27 years. Majority of patients 81 (28.8%) were in the age range of 21 – 30 years. EDH was found in 31 (11.03%) patients. Eleven patients (3.91%) had their hemato-mas in temporal region. Temporo-parietal region was involved in 9 (3.2%) patients. Frontal and parietal region was affected in 5 patients (1.78%) each. One patient had extra-dural hematoma in posterior cranial fossa.Conclusion: Extra-dural haematoma is fond in 11% of head injury cases. It is more contain in males as com-pared to females. It is most common in 20 – 40 years of age, temporal and parallel cases are most frequently in-volved regions. The mortality in head injury patients can be reduced if extra-dural hematoma diagnosis and operation done early

Transnasal Trasnssphenoidal Surgery for Pituitary Tumours

Objective: To determine the frequency of early post-operatively complications of transnasal transsphenoidal surgery for pituitary adenoma.Study design: Descriptive study.Place and Duration of Study: Pak International Medical Science Khyber Pakhtoonkhawa from 1st February 2008 to 31st July 2011.Material and methods: A total 41 patients with pituitary adenoma fulfilling the inclusion and exclusion criteria were included in this study. All patients were undergone transnasal transsphenoidal surgery. These patients were followed up for early complications of transsphenoidal surgery for one month.Results: Out of 41 patients, there were 23 (56.09%) males and 18 (43.9%) females. The age of patients ranged from 10 to 70 years. In this study the overall mean age was 44.75 years. Majority of patients fourteen (34.14%) were in the age range of 41 – 50 years, followed by eleven (26.8%) patients in age group of 31 – 40 years, seven (17.07%) patients were in the age range of 51 – 60 years, five (12.1%) in the age range of 61 – 70 years, three (7.31%) in the age group of 21 – 30 years and one (2.4%) in the age group of 10 – 20 years. Early post-operative complications were diabetes insipidus in four (7.31%) patients, CSF leak two (4.87%) patients, meningitis in one (2.43%) patient and epistaxis in one (2.43%) patient.Conclusions: Surgical complications of Transnasal transsphenoidal surgery are minimal. Transnasal trans-sphenoidal surgery is a safe and effective treatment for pituitary tumour

Complications Following Posterior Fossa Tumour Surgery in Children: Experience from a Tertiary Care Neurosurgical Facility in a Developing Country

Background: Posterior fossa tumours are the commonest childhood brain tumours with diverse clinical presentations, treatment modalities and postoperative outcomes. The literature has limited description of postoperative complications following surgery for these tumours. Objective: The aim of this study is to analyse the postoperative complications, which occur after PFT surgery in children. A brief overview of the in-hospital mortality and management of these complications presented. Materials and Methods: This is a retrospective chart review of children who were operated for PFTs. The occurrence of complications during the postoperative period was noted. Complications management, in-hospital mortality and overall survival was also recorded until the time of discharge. The complications are divided according to the modified Clavien-Dindo classification and outcome was stratified accordingly. Results: 79 (60.3%) males and 52 (39.7%) females with a mean age of 8.15 ± 3.3 years. The mean duration between symptoms onset and diagnosis was 35.3 ± 16.6 days. Overall, there were 53 (40.5%) cases of medulloblastoma, 40 (30.5%) cases of ependymoma, 34 (26.0%) cases of pilocytic astrocytoma and only 4 (3.1%) cases of atypical teratoid/rhabdoid tumours. Twenty-five (19.1%) patients developed hydrocephalous postoperatively. The most common complication was postoperative incisional CSF leak, which occurred in 17 (13.0%) patients. Wound infection was noted in 8 (6.1%) patients, eight (6.1%) of patients presented with cerebellar mutism, five (3.8%) patients had bleed in tumour bed, five (3.8%) patients had aspiration pneumonia and 7 (5.3%) patients developed hospital acquired pneumonia. The overall mean length of stay (LOS) was 5.4 ± 2.2 days (range: 3 – 12 days). The overall mortality rate was 9.9% (n = 13). Conclusion: The most common complication is the development of hydrocephalous, followed by cerebrospinal fluid leaks, cerebellar mutism, peri-tumour oedema, tumour bed haematoma and systemic complications such as meningitis, sepsis and postoperative pneumonia.&nbsp

Clinical Manifestation of Brain Abscess

Objective: To determine the clinical presentations of brain abscess.Study design: Descriptive study.Place and Duration of Study: Hayatabad Medical Complex Hospital Peshawar Khyber Pakhtoonkhawa from 1st February 2001 to 31st July 2011.Material and Methods: A total 31 patients with symptomatic brain abscess confirmed on CT scan were included in this study. Both gender (male and female) and patients in the age range of 01 – 70 years were included in this study. The patients’ demographic details and clinical manifestation were entered into a semi structured proforma. Data was analyzed through statistical program SPSS version 11.Results: Out of 31 patients, there were 17 (54.8%) males and 14 (45.2%) females. The age of patients ranged from 01 to 70 years. In this study the overall mean age was 32.38 years. Majority of patients 13 (41.9%) were in the age range of 31 – 40 years. Most common clinical presentation of patient were headache in 29 (93.5%) vomiting 22 (71%) and fever 13 (42%) patients.Conclusions: Brain abscess commonly occurred in the third decade of life. Headache vomiting and fever were the most common clinical presentation of brain abscess

Outcome of Endoscopic Third Ventriculostomy (ETV)

Objective: To know the surgical outcome of endoscopic third ventriculostomy (ETV) in non communicating hydrocephalous.Materials and Methods: This cross sectional descriptive study was done in the department of neurosurgery PGMI / Hayatabad Medical Complex, Peshawar, from 2nd February 2011 to 1st march 2012. A total of 35 patients with non-communicating hydrocephalous, irrespective of gender discrimination were included in this study. Patients below two years of age and hydrocephalus with infected CSF or hemorrhage were excluded. Hydro-cephalous was diagnosed on CT scan brain. The information regarding patient demographical details, causes of hydrocephalus and complications of procedure were documented in patient’s Performa. The data was analyzed by SPSS version 17. Frequency and percentage was calculated for categorical variables. Mean ± SD was calcu-lated for age. Results were presented as tables.Results: A total of 35 patients with non-communicating hydrocephalous were included in the study. Out of 35 patients, there were 22 (62.8%) males and 13 (37.21%) females. The mean age was 21 years. Etiologically tuber-culous meningitis was the commonest cause of non communicating hydrocephalous. Post-operatively CSF leak-age was present in 3 (8.6%) patients, pseudomeningocele in 2 (5.7%) patients, transient memory loss in 1 (2.8%) and pneumo-cephalous in 1 (2.8%).Conclusion: The complications of endoscopic third ventriculostomy are transient. Those patients who meet the criteria, endoscopic third ventriculostomy offers the possibility of freedom from shunt dependency

Management of Cervical Neurofibroma Type

Objective: To determine the clinical presentation and postoperative outcome of cervical neurofibroma type 1.Study design: Retrospective study.Place and Duration of Study: Hayatabad Medical Complex Hospital Peshawar Khyber pakhtoonkhawa from 1st February 1999 to 31st July 2011.Material and Methods: A total 41 patients with symptomatic cervical spine neurofibromas who underwent surgical decompression and tumor resection were included in this study. Both gender (male and female) and patients in the age range of 20 – 70 years were included in this study. These patients were operated through posterior approach of the cervical spine and then followed for six months for postoperative outcome .The patients’ demographic details and clinical manifestation were entered into a semi structured proforma. Data was analyzed through statistical program SPSS version 11.Results: Out of 41 patients, there were 22 (53.6%) males and 19 (46.3%) females. The age of patients ranged from 20 to 70 years. In this study the overall mean age was 39.2 years. Majority of patients 19 (46.3%) were in the age range of 31 – 40 years. Most common clinical presentation of patient were quadrapresis in 23 (56.1%) pain neck 9 (22%) paraparesis 9 (22%) patients. Postoperatively most of the patients recovered from their preoperative symptoms.Conclusions: Quadraparesis and pain neck were the common clinical presentation of cervical cord neurofibroma type 1. Surgical outcome of cevical neurofibroma type 1 is good