Framed Stereotactic Brain Biopsy Outcome – Single Center Study

stereotactic biopsy. The study was conducted at the Neurospinal & Cancer Care Institute Karachi. Material and Methods:  After the approval from the ethical hospital committee, the study was conducted on 34 patients, in which 9 (26.4%) were females, and 25 (73.5%) were males. 34 consecutive patients with biopsy inclusion deep seated lesion, mid line pathology, eloquent area and operated surgery, previous radiation treatment were excluded, and after that, the biopsy report based surgery or radiotherapy treatment was decided. Result:  The biopsy underwent histopathological diagnosis proving Astrocytoma in 7 (20.5%) patients out of which four were in the Eloquent area, tuberculosis diagnosed in 5 (14.7%) patient, Oligodendroglioma diagnosed in 3 (8.8%) patients, metastasis in 5 (14.7%), Abscess in 4 (11.7%) patient which was aspirated to maximum and sent for culture, Malignant tumor (grade 3 & 4) 5 (14.7%), Lymphoma in 2 (5.8%) patient both were given radiation therapy Tumor necrosis 1 (2.9%) case,  and No tissue obtained in 2 (5.8%) which was repeated later. No major complication or side effects were observed in the patient. Conclusion:  Stereotactic Framed biopsy is safe and accurate and can be used in deep seated lesions with high success rate, minimal complication and decrease surgical morbidity for patients, and it is comparable to updated methods. &nbsp

Craniosynostosis: Clinical Presentation and Outcome of Surgical Treatment

Objective:  Craniosynostosis presents sclerosis cranial sutures, ossification and fusion involving the vault of the base, sutures involved can be one or more sutures. This study aimed to determine the surgical outcome of craniosynostosis. Material and Method:  The prospective study was conducted at the neuro spinal and cancer care institute, Karachi. Patients presented with sagittal, metopic, unicoronal, lambdoid, bicoronal craniosynostosis were included in the study, while patients with coagulopathy, previously operated cases were excluded from the study. Results:  We had 26 children in our study, age range about 1–3 years. Patients were cleaved into groups depending on their age. Most of the children 15 (57.6%) were in 1–2 years age group and 11 (42.3%) were in 2-3 years of age. Boys were 18 (69.2%) and girls were 8(30.7%). Coronal 11 (42.3%) was the most common suture involved, followed by sagittal 9 (34.6%). Lambdoid suture 3 (11.5%), metopic 2 (7.6%) and 3 (11.5%) case presented with raised intracranial pressure with multiple sutures closed involved. Strip craniectomy was done in all cases. We did bicoronal flap and Scalp flap turned into a supraorbital region while in metopic suture Fronto-orbital advancement and remodeling approach were used. No major complication was observed. Conclusion:  Cases which are managed early age have given good acceptable results in follow up, proper surgical expertise, perioperative management of temperature, blood loss, relieving the restriction of sutures and normalizing raised intracranial pressure can decrease the morbidity and mortality

Cervical Spine Discectomy, Osteo-facetectomy by Noble Art of Cloward Procedure and Its Modification- A Single Centre study

Objectives: To analyze the surgical outcome of cervical spine osteo-facetectomy discectomy, and modified Cloward procedure.Materials and Methods: A prospective study was conducted at the Neurospinal & cancer care institute, Karachi. The duration of study was from 1st June 2017 to 25th November 2019. Patients having prolapsed intervertebral cervical discs included in the study, while those with trauma, cervical radiation, previous cervical surgery andmultiple level involvement were excluded. Pre and post-surgical data was collected. Titanium Hashmi cage was used in all operated patients at single level instrumentation.Results: A total of 113 patients satisfied the inclusion criteria and were considered in the study. Among them, 77 patients were male and 36 were female. The age range from 26 to 65 with a base age of 53 years ± 2.5. C5 – C6 was the commonest level for fusion C6 – C7, C3 – C4 and C4 – C5 were less common. For the outcome of theprocedure Odom’s criteria, was followed the results showed excellent improvement in 88 (77.87%), Good results in 18 (15.9%), fair in 5 (4.42%) and 2 patient had Poor (1.76%) results. Fusion was seen in 86 patients, superficial infection in two cases.Conclusion: Patients with single-level degenerative disc and treated with modified titanium Hashmi cage provided a good fusion with the relief of upper limb pain without donor site morbidity at anterior iliac spine

Outcome of Essential Tremors with Stereotactic Thalamotomy: Noble Art of Lesioning

Objective:  Objective of study is to identify the effects of Stereotactic thalamotomy of the nucleus ventral intermediate (VIM) for treatment of essential tremor. Material and Methods:  This is a descriptive study.It was performed at NCCI, Karachi, duration of study was 7 years, from 2-10-2012 to 7-10-2019. Those patients were included who were with tremors refractory to medication, their duration of disease was > 3 years, and with grade 4 tremors. The thalamotomy was performed in all cases, and follow-up was conducted at 3, 6, and 12 months respectively. The success of the surgery was measured in the form of a reduction in medication number and reduction in dose >50% and by calculating the Essential Tremor Rating Assessment Scale (tetras). Results:  Total of 26 patients were included. All patients showed remarkable improvement post-procedure at 12 month follow-up. 20 (77%) patient required no medications. In 6 (23%) patients, the dose of medication was reduced to less than half post-treatment. The tetras score showed marked improvement in all a patient; 4 (15%) patients who had grade 4 tremor, showed the symptoms of minimal tremors graded 0.5 on last visit 3rd visit. Side effect post-procedure were mild transient numbness on the contralateral side was observed in 11 (42.3%) patient, 1 (3.8%) patient had dysarthria. Conclusion:  We concluded that stereostatic Ventral intermedius nucleus thalamotomy was effective in reducing tremor grades and improved all functionality with few mild side effects

The Outcome of Subaxial Cervical Injury in Adult Patients Managed Surgically Through an Anterior Approach

Objectives:  We determined the Outcome of subaxial cervical injury management in adults through anterior approach open reduction and fixation injury < 72 hours. Material and Methods:  A total of 71 patients declared to have a recent chronicle of traumatic cervical spine injury with a conventional diagnosis of subaxial injury by Magnetic Resonance Imaging (MRI) and X-Ray anteroposterior and lateral views. ASIA Impairment Scale was used for assessment and was done at the time of admission and after six months. Results: Mean age of the patients in our study was 38.54 ± 5.47 years. According to American Spinal Injury Association (ASIA) scale, improvement by two grades was seen in 18 cases and improvement by one – grade was observed in 48 cases. Mortality was seen in 5 cases, where 2 deaths were related to associated injury, one related to a complication of surgery and other 2 died due to aspiration complications. Out of 66 cases, the outcome was good in 49 (74.29%) and fair in 17 (25.76%). Conclusion:  The study results revealed that Anterior Cervical Discectomy and Fusion (ACDF) is considered to be a better treatment choice for better anatomical stabilization of the spine with early reduction. Keywords:  Subaxial cervical injury, anterior approach, ASIA (American Spinal Injury Association) scoring

Transpedicular Fixation via Posterior Approach for Dorsal and Lumbar Spine Tuberculosis

Objective:  To determine the outcome of Transpedicular Fixation via Posterior Approach for Dorsal and Lumbar Spine Tuberculosis. Material/Methods:  This study was cross-sectional and conducted from 01/02/2015 to 30/7/2020 in the department of neurosurgery. A total of 36 patients with dorsal and lumbar spine tuberculosis were operated on for transpedicular fixation. Assessment scores were used pre-operative and post-operative and patients were kept on follow-up till six months after the surgical procedure. Variables like age, gender, spinal level, preoperative, and follow-up clinical status were calculated. Results:  There were 19 (53%) male and 17 (47%) female patients with a mean age of 27 ± 8. Thoracolumbar was the commonest segment involved in 17 (47%) patients, followed by lower thoracic in 8 (22%) and lumbar in 7 (19%). There were 7 (19%) patients on the preoperative American Spinal Injury Association (ASIA) impairment scale in grade B, 12 (33%) in grade C, 15 (42%) in grade D, and 2 (5%) in grade E. The follow-up assessment at 6 months showed that ASIA grade B was seen in 3 (8%), grade C in 4 (11%), grade D in 16 (44%), and Grade E in 13 (36%) patients. Preoperative and follow-up scores on the ASIA impairment scale, COBS ANGLE, and ESR showed a significant difference (p-value < 0.05). Conclusion:  We concluded that transpedicular fixation can restore the stability of the spine in thoracic and lumbar tuberculosis. The procedure is important for the improvement of clinical symptoms, correction of kyphosis, and stabilization of the spinal column

Outcome in Normal Pressure Hydrocephalus after Ventriculoperitoneal Shunt in Tertiary Care Hospital

Objective:  To determine the outcome of the ventriculoperitoneal shunt in normal pressure hydrocephalus. Material and Methods:  This study was conducted at Jinnah Postgraduate Medical Centre, a tertiary care hospital in Karachi. Patients with idiopathic normal pressure hydrocephalus (NPH) were included. Gender distribution, presentation of symptoms and post-operative outcome based on the Stein Langfitt Scale were assessed. CSF was sent for microbiological and biochemical analyses. All patients were evaluated preoperatively and compared postoperatively during 6 months duration for improvement and any associated complication. Results:  In this study, we had 47 patients, 38 were male and 9 were female. 22 patients presented with dementia, 18 with urinary incontinence, 17 with gait disturbance 17, while 21 had headache based on Stein and Langfitt Scale. The 78.8% patients had an excellent outcome, 17% had a good outcome and 4.2% had poor results. Conclusion:  Ventriculoperitoneal (VP) shunt had promising results selected on history and examination of normal pressure hydrocephalus and improved radiological in Evan’s ratio CT brain scan. Keywords:  Normal Pressure Hydrocephalus (NPH), VP Shunt, Stein and Langfitt Scale

Assessment of Modes of Injury and Outcome in Patients with Traumatic Posterior Fossa Extradural Hematomas: A Study of a Tertiary Care Hospital

Objective:  The aim of study to assess the prevalence of divergent modes of injuries in traumatic posterior fossa extradural hematomas (PFEDH) along with the description of surgical and clinical management. Material and Methods:  A descriptive study was performed at the Jinnah Postgraduate Medical Centre (JPMC), Karachi from May 2014 to October 2020. Total 37 patients who presented with posterior hematoma of any age and gender were included. CT scan Brain plain with the bone window was performed for a basic diagnosis to assess the volume, and any associated fracture, or any injury in the posterior fossa. The outcome was calculated from the scores of the Glasgow Coma Scale (GCS). Results:  70% were male and around 30% were female patients. The mean calculated age was 32 ± 5.33 years. A road traffic trauma was the major cause of brain injury in 25 (67.56%) cases. The majority (56.75%) of patients reported headache, nausea and vomiting. 35% of patients were conservatively managed, with an average hematoma size of 3 cm on CT scan and GCS > 12 while 64.86% patients were operated, with the average size of hematoma > 3 cm and GCS < 10 while 61% of the patient had an occipital fracture. The majority of patients (8.1%) reported complications such as brain contusions and post-traumatic hydrocephalus. Conclusion:  Post fossa EDH should be managed aggressively, especially those with low GCS (< 8), and volume > 3 cm. Patients who are to be managed conservatively also require close observation. &nbsp

Multimodality Treatment of Craniopharyngioma: Aspiration of Cystic Contents and Placement of Ommaya Reservoir Stereotactically Followed by Gamma Knife Radiosurgery – Single Center Study of 81 Cases

Objective:  The objective of this present study was to assess the accuracy, result, and safety measures of stereotactic biopsy. The study was conducted at the Neurospinal & Cancer Care Institute Karachi. Material and Methods:  After the approval from the ethical hospital committee, the study was conducted on 34 patients, in which 9 (26.4%) were females, and 25 (73.5%) were males. 34 consecutive patients with biopsy inclusion deep seated lesion, mid line pathology, eloquent area and operated surgery, previous radiation treatment were excluded, and after that, the biopsy report based surgery or radiotherapy treatment was decided. Result:  The biopsy underwent histopathological diagnosis proving Astrocytoma in 7 (20.5%) patients out of which four were in the Eloquent area, tuberculosis diagnosed in 5 (14.7%) patient, Oligodendroglioma diagnosed in 3 (8.8%) patients, metastasis in 5 (14.7%), Abscess in 4 (11.7%) patient which was aspirated to maximum and sent for culture, Malignant tumor (grade 3 & 4) 5 (14.7%), Lymphoma in 2 (5.8%) patient both were given radiation therapy Tumor necrosis 1 (2.9%) case,  and No tissue obtained in 2 (5.8%) which was repeated later. No major complication or side effects were observed in the patient. Conclusion:  Stereotactic Framed biopsy is safe and accurate and can be used in deep seated lesions with high success rate, minimal complication and decrease surgical morbidity for patients, and it is comparable to updated method

PET-CT Guided Gamma Knife Radiosurgery for Recurrent Glioblastoma Multiforme Recurrent Cases in Pakistan

Objective:  The treatment of recurrent Glioblastoma Multiforme (r-GBM) poses a significant confronts to neurosurgeons. This study was conducted to assess the effectiveness of PET-CT-guided Gamma Knife radiosurgery (GKRS) in treating r-GBM. The purpose of the study is to determine the outcome of this treatment approach. Materials and Methods:  Retrospective descriptive research was supervised at the Neurospinal and Cancer Care Institute, Karachi Pakistan between June 2017 to August 2022. The study comprised patients with biopsy-confirmed Grade IV Glioblastoma Multiforme who experienced recurrence during follow-up. PET-CT and MRI brain with contrast were performed to determine the target volume of the tumor, and GKRS was carried out based on the scan findings. Results:  A total of 24 patients, ranging in age from 47 to 77 years with a median age of 50 years, were included in the study. The tumor recurrence occurred within a median interval of 10 months after diagnosis, ranging from 1 to 16 months. The median time for progression-free survival from GKRS was 5 months, ranging from 2 to 6 months. The median overall survival from GKRS was 11 months, ranging from 5 to 12 months. Conclusion:  GKRS is a tool in the multimodal treatment of r-GBM. By co-registering PET-CT-MRI, it becomes possible to plan the treatment more effectively by targeting the active tumor while preserving healthy brain tissue. This approach has the potential to improve overall survival rates and patient outcomes