Monetary impact of Taenia solium cysticercosis in four countries

The societal monetary burden of cysticercosis in the Eastern Cape Province, South Africa, Honduras, India and the United States of America were estimated. Data on the frequency of infection and on associated morbidity in both human and pig populations and their costs were collected. Decision trees were used to assess the frequency of medical care and loss of value of pigs with their monetary impact

Whither lesional surgery for movement disorders

Stereotactic surgery gained relevance in neurosurgery mainly as a surgical procedure to ameliorate symptoms of Parkinson's disease (PD) and other movement disorders. However stereotactic surgery for movement disorders has experienced fluctuating fortunes with a fall in the 1970s and resurgence in the 1990s. Lesional surgery for PD and other movement disorders gained momentum after the publication of the landmark article on pallidotomy by Laitinen et al in 1992.[1] This led to renewed interest in functional stereotactic surgery particularly pallidotomy in patients with PD. The interest in pallidotomy and thalamotomy, however, has died down in recent years due to emergence of deep brain stimulation (DBS). DBS is touted as being superior to lesional surgery such as thalamotomy and pallidotomy, as it does not destroy brain tissue and therefore, adverse effects, if any, of the stimulation are reversible unlike lesional surgery where the adverse effects of destruction of the target site are likely to be permanent. However, there have been very few articles discussing all the pros and cons of lesional surgery and DBS. In recent years DBS has almost completely replaced thalamotomy and pallidotomy in most developed countries. The question being raised in this editorial is whether lesional surgery is still relevant and whether it should be promoted amongst neurologists, neurosurgeons and patients as a safe and effective surgery for selected patients with PD and other movement disorders. The author is not exploring the relative merits and drawbacks of the two procedures (lesional surgery and DBS) to arrive at a conclusion regarding the superiority of one of the procedures. The purpose of this editorial is only to evaluate the evidence on the safety, efficacy and durability of lesional surgery for movement disorders

Neurocysticercosis: Diagnostic problems & current therapeutic strategies

Neurocysticercosis (NCC) is the most common single cause of seizures/epilepsy in India and several other endemic countries throughout the world. It is also the most common parasitic disease of the brain caused by the cestode Taenia solium or pork tapeworm. The diagnosis of NCC and the tapeworm carrier (taeniasis) can be relatively inaccessible and expensive for most of the patients. In spite of the introduction of several new immunological tests, neuroimaging remains the main diagnostic test for NCC. The treatment of NCC is also mired in controversy although, there is emerging evidence that albendazole (a cysticidal drug) may be beneficial for patients by reducing the number of seizures and hastening the resolution of live cysts. Currently, there are several diagnostic and management issues which remain unresolved. This review will highlight some of these issues

Management of hydrocephalus in patients with tuberculous meningitis

Hydrocephalus is one of the commonest complications of tuberculous meningitis (TBM) occurring in up to 85% of children with the disease. It is more severe in children than in adults. It could be either of the communicating type or the obstructive type with the former being more frequently seen. The Vellore grading system for clinical grading of patients with TBM and hydrocephalus with grade I being the best grade and grade IV being the worst grade has been validated by several authors. The management of hydrocephalus can include medical therapy with dehydrating agents and steroids for patients in good grades and those with communicating hydrocephalus. However, surgery is required for patients with obstructive hydrocephalus and those in poor grades. Surgery can involve either a ventriculo-peritoneal shunt or endoscopic third ventriculostomy (ETV). Complications of shunt surgery in patients with TBM and hydrocephalus are high with frequent shunt obstructions and shunt infections requiring repeated revisions. ETV has variable success in these patients and is generally not advisable in patients in the acute stages of the disease. Mortality on long-term follow up has been reported to vary from 10.5% to 57.1% in those with altered sensorium prior to surgery and 0 to 12.5% in patients with normal sensorium. Surgery for patients in Vellore grade IV is usually associated with a poor outcome and high mortality and therefore, its utility in these patients is debatable

Surgical management of intracranial fungal masses

Background: Intracranial fungal masses (IFMs, granulomas and abscesses) are uncommon lesions, infrequently encountered by neurosurgeons. There is no conclusive evidence on the ideal surgical management of these lesions. Aims: To summarize the recent literature on the prevalence, presentation, surgical management and outcome of patients with IFMs. Materials and Methods: The recent published literature was searched using standard search engines (PubMed and Google) for articles reporting on the databases and surgical management of IFMs. A special effort was made to include publications from Indian centers. Results: Intracranial fungal masses were rarely seen even in major neurosurgical centers in India with a prevalence of around one to two per year. While most patients with IFM have immunosuppressed states, nearly 50% of patients with IFMs (especially in India) have no obvious predisposing causes and are apparently immunocompetent. The clinical presentation could be categorized into three groups: 1. Involvement of the cranial nerves 1 to 6 with orbital and nasal symptoms. 2. Focal neurological deficits due to involvement of any part of the neuraxis; and 3. "Stroke-like" presentation with sudden onset of hemiparesis. Based on the presence or absence of radiological evidence of paranasal sinus disease, IFMs were classified into two types: 1. Rhinocerebral type; 2. Purely intracranial type that was further divided into a. intracerebral or b. extracerebral forms. Aspergillus species was the commonest fungal organism causing IFMs but a number of other fungi have been reported to cause IFMs. Surgery for IFMs can be of different types, namely 1. Stereotactic procedures; 2. Craniotomy; 3. Shunt surgery; and 4. Treatment of fungal aneurysms. Generally, radical surgery is advocated for IFMs but there is no unanimity regarding the radicality of the excision especially for the rhinocerebral form of the disease. Surgery should always be followed by antifungal therapy for prolonged periods. Mortality and morbidity in patients with IFMs is very high and ranges from 40-92%. Immunosuppressed patients with IFMs and those in whom the diagnosis is delayed have the highest mortality rates, with immunocompetent patients with the rhinocerebral form of the disease having the best outcome. Conclusions: There should be a high index of suspicion for IFMs not only in patients with known risk factors for the development of fungal infections but also in immunocompetent patients in India. Intraoperative pathological diagnosis should be obtained in any patient suspected to have an IFM and tissue should be processed for fungal cultures. Prompt diagnosis, radical and safe surgery and aggressive and prolonged treatment with anti-fungal agents may lead to a better outcome especially in immunocompetent patients

Surgical management of intracranial fungal masses

Background: Intracranial fungal masses (IFMs, granulomas and abscesses) are uncommon lesions, infrequently encountered by neurosurgeons. There is no conclusive evidence on the ideal surgical management of these lesions. Aims: To summarize the recent literature on the prevalence, presentation, surgical management and outcome of patients with IFMs. Materials and Methods: The recent published literature was searched using standard search engines (PubMed and Google) for articles reporting on the databases and surgical management of IFMs. A special effort was made to include publications from Indian centers. Results: Intracranial fungal masses were rarely seen even in major neurosurgical centers in India with a prevalence of around one to two per year. While most patients with IFM have immunosuppressed states, nearly 50% of patients with IFMs (especially in India) have no obvious predisposing causes and are apparently immunocompetent. The clinical presentation could be categorized into three groups: 1. Involvement of the cranial nerves 1 to 6 with orbital and nasal symptoms. 2. Focal neurological deficits due to involvement of any part of the neuraxis; and 3. "Stroke-like" presentation with sudden onset of hemiparesis. Based on the presence or absence of radiological evidence of paranasal sinus disease, IFMs were classified into two types: 1. Rhinocerebral type; 2. Purely intracranial type that was further divided into a. intracerebral or b. extracerebral forms. Aspergillus species was the commonest fungal organism causing IFMs but a number of other fungi have been reported to cause IFMs. Surgery for IFMs can be of different types, namely 1. Stereotactic procedures; 2. Craniotomy; 3. Shunt surgery; and 4. Treatment of fungal aneurysms. Generally, radical surgery is advocated for IFMs but there is no unanimity regarding the radicality of the excision especially for the rhinocerebral form of the disease. Surgery should always be followed by antifungal therapy for prolonged periods. Mortality and morbidity in patients with IFMs is very high and ranges from 40-92%. Immunosuppressed patients with IFMs and those in whom the diagnosis is delayed have the highest mortality rates, with immunocompetent patients with the rhinocerebral form of the disease having the best outcome. Conclusions: There should be a high index of suspicion for IFMs not only in patients with known risk factors for the development of fungal infections but also in immunocompetent patients in India. Intraoperative pathological diagnosis should be obtained in any patient suspected to have an IFM and tissue should be processed for fungal cultures. Prompt diagnosis, radical and safe surgery and aggressive and prolonged treatment with anti-fungal agents may lead to a better outcome especially in immunocompetent patients

Management of hydrocephalus in patients with tuberculous meningitis

Hydrocephalus is one of the commonest complications of tuberculous meningitis (TBM) occurring in up to 85% of children with the disease. It is more severe in children than in adults. It could be either of the communicating type or the obstructive type with the former being more frequently seen. The Vellore grading system for clinical grading of patients with TBM and hydrocephalus with grade I being the best grade and grade IV being the worst grade has been validated by several authors. The management of hydrocephalus can include medical therapy with dehydrating agents and steroids for patients in good grades and those with communicating hydrocephalus. However, surgery is required for patients with obstructive hydrocephalus and those in poor grades. Surgery can involve either a ventriculo-peritoneal shunt or endoscopic third ventriculostomy (ETV). Complications of shunt surgery in patients with TBM and hydrocephalus are high with frequent shunt obstructions and shunt infections requiring repeated revisions. ETV has variable success in these patients and is generally not advisable in patients in the acute stages of the disease. Mortality on long-term follow up has been reported to vary from 10.5% to 57.1% in those with altered sensorium prior to surgery and 0 to 12.5% in patients with normal sensorium. Surgery for patients in Vellore grade IV is usually associated with a poor outcome and high mortality and therefore, its utility in these patients is debatabl

Trolley-mounted head rest for fixing the BRW head ring in supine patients

A simple head rest that can be mounted on an operating room trolley and facilitates fixation of the BRW stereotactic head ring in the anaesthetized or semiconscious patients is described

Continuous impedance monitoring during CT-guided stereotactic surgery: relative value in cystic and solid lesions

Continuous monopolar impedance monitoring was performed during CT-guided stereotactic procedures involving 46 probe passages in 33 patients. Four readings were obtained during each passage to the lesion corresponding to the gray matter (A), subcortical white matter (B), perilesional tissue (C), and the target (D). The mean impedance of low-grade gliomas (442.7 ± 96.1 SD ohm) was lower than that of high-grade gliomas (675 ± 67.3 SD ohm) (p = 0.01). But because of considerable overlap of values in the 400-700 ohm range only impedances of less than 400 ohm and greater than 700 ohm are capable of predicting pathology, the former being associated with low-grade gliomas and the latter with high-grade gliomas. The mean change in impedance from the perilesional tissue to the target (C-D) was higher for cystic lesions compared with the solid lesions (127.5 ± 131.5 SD versus 78.9 ± 72.4 SD ohm) but was not statistically significant (p = 0.148). Impedance monitoring was found to be particularly useful in determining the entry into thick-walled cysts. It also helped elucidate the structures encountered in the probe track. Overall this procedure is a simple and useful adjunct, which can enhance the accuracy of selected CT-guided procedures without unduly increasing the length of the procedure or altering the morbidity