Management of Post Traumatic Epilepsy in Pediatric Population in Pakistan

Objective:  To investigate the efficacy of seizure prophylaxis in the prevention of early and late-onset seizures after the traumatic brain injury known as post-traumatic epilepsy (PTE). Material and Methods:  A retrospective study was performed on children aged 0 to < 12 years who were presented to a level 1 trauma center during the six months with the diagnosis of mild to severe TBI. Data included is of 66 patients from Children’s Hospital, Lahore. It was analyzed according to a patient’s demographic data, mechanism of injury, clinical and radiological presentation, management, and follow-up. History of seizures was tracked through guardian referral or staff witnesses. Results:  Among 66 pediatric cases of acute brain injury from June 2019 to December 2019, 45 were males (68%) and 21 were females (32%) with a male to female ratio of 2:1. The mean age in our study was 3.8 years. 60% of children were managed under observation, 30% of children required medical pharmacological treatment, 9% of children needed surgical intervention, and 13% of children required artificial ventilation. Overall mortality is 4.5%. In our study, we found a considerable relationship between residual neurological deficits and severity of injury (p = 0.3), there is no noteworthy relationship between mechanism of injury and outcome (p = 0.5). The mean length of stay was 3.9 days but 60% of patients had stayed less than 3 days. Conclusion:  Analyzing the underlying mechanisms of post-traumatic epilepsy can lead us to propose effective treatments to prevent seizures following traumatic brain injury

Endoscopic Third Ventriculostomy: A Comparable Alternative to Ventriculoperitoneal Shunt for Obstructive Hydrocephalus Secondary to Infratentorial Tumors

Objective: To establish ETV  as a comparable alternative to ventriculoperitoneal shunt for obstructive hydrocephalus secondary to infratentorial tumors. Methods: 40 Patients with infratentorial tumors presenting with hydrocephalus were enrolled in a prospective descriptive case series. Symptoms, neurological examinations, CT scan and intra-operative findings were used detect the complications at 03 months. Results:   Mean age = 31.98 ± 15.24 years, female to male ratio of 1:1.2. The KPS score of the participants was ? 70% and ETVSS ?80. Average operative mean time was 21 ± 2.82 minutes. Within first week, the improvement in symptoms was recorded (CI=95%): headache – 87.5% (p < 0.001), nausea vomiting - 84% (p < 0.001), gait disturbance – 59.3% (p=0.442) seizures improvement -100% (p=0.016) and urinary incontinence – 66.7% (p=0.687). Radiological improvement in hydrocephalus on CT scan was seen in one patient within 24 hours – 2.5% (p= <0.001), 12.5% (p<0.001) after two weeks and 87.5% (p= <0.001) after three months post-operatively (CI 95%). Most common of these were decrease in the size of third ventricle and decrease in the size of frontal horns of lateral ventricles.  However, complete resolution of radiologic features was observed in two patients only 5% (p<0.001). However, complete resolution of radiologic features was not observed in any patient. No intra-operative or post-operative complication of ETV was recorded. Conclusion: ETV is a quick and safe method for CSF diversion in obstructive hydrocephalus alleviating the need for placement of VP shunt hardware, thus eliminating foreign body related cranio-abdominal complications

Outcome of Endoscopic Discectomy in Patients with Lumbar Prolapsed Intervertebral Disc

Objective: To determine the outcome of endoscopic discectomyin patients with lumbar prolapsed intervertebral disc in terms of back pain and leg pain using the visual analogue scale.Material and Methods: Descriptive case series, was conducted at, PINS, LGH Lahore for 6 months. 15 patients were included through non probability consecutive sampling that fulfilled inclusion criteria. All patients’ low back pain and leg pain was documented using visual analogue scale before and after 2 months of surgery.On the basis of VAS we calculated % age improvement of low back pain and leg pain after endoscopic discectomy, while ≥ 5 scale improvement was considered clinically significant.Results: Patients mean age was 44.46 years. Among them, 9 (60%) were males and 6(40%) were females. On average, the basal metabolic index (Kg/m2) was 29.29 However, the BMI of females was 31.76 and male was 27.65 Kg/m2. On average, the duration of symptoms was 8.05 months. On average, the Straight Leg Raise was 24.7o at the time of treatment. A decreased sensation was observed in L5 of 3 (20%) and in S1 of 4 (26.67%) participants. Whereas Absent sensation was observed in L5 of 3(20%) and in S1 of 5 (33.33%). Mean preoperative back pain and as well as leg pain was 7.05 that improved to 0.41 and 0.86 4 weeks post operatively.Conclusion: Endoscopic discectomy is equally effective in alleviating the symptoms without notable difference in surgical outcome

Surgical Outcome of Traumatic Posterior Fossa Extradural Hematoma in Paediatric Population: Our Experience at UCHS, The Children’s Hospital, Lahore

Objective:  Most common location for Extradural hematoma (EDH) is within the supratentorial region. The incidence of Posterior fossa extradural hematoma (PFEDH) is1.2% to 12.9% of all EDH. The purpose of this study is to evaluate the management, clinical outcomes, and epidemiological features of posterior fossa EDH. Materials and Methods:  A cross-sectional study was conducted at the department of pediatric neurosurgery Children Hospital and the University of child health sciences, Lahore from September 2021 to December 2021. Thirty patients presented with posterior fossa extradural hematoma in the pediatric age group were included. A plain CT scan Brain with the bone window was done for initial diagnosis to assess any injury in the posterior fossa including volume of hematoma and any associated fracture. Glasgow Coma Scale (GCS) was used to evaluate the outcome. Results:  Twenty-five patients were surgically treated, and five patients were managed conservatively. There was no mortality observed and the overall results were good in all the patients. Conclusion:  As compared to supratentorial extradural hematoma the Posterior fossa epidural hematoma is uncommon. For all suspected cases early and serial CT scans must be carried out. There was an excellent prognosis in pediatric patients who underwent surgical management

Incidence of Epilepsy and Drug Dependence after Post Traumatic Contusions Managed Conservatively

contusions managed conservatively. Material and Methods:  A prospective observational study was carried out in, Punjab Institute of Neurosciences, Lahore. A total of 97 patients, from 15-65 years, who were diagnosed with cerebral contusions and being managed conservatively were enrolled from July 2019 to December 2019. They were followed-up for 12 – 18 months. Results:  A total of 23% patients developed early post-traumatic seizures (PTS) and 11% of patients developed late post-traumatic seizures with mild to moderate brain injury.6% of patients with early PTS used antiepileptic drugs (AED) for at least three months during follow up and 7% with late PTS used AED. 8% of patients developed late PTS without any early PTS. The results of our study show that among 23% early PTS and 11% late PTS only 3 % actually required to use AED for at least 6months. To prevent this, 3% of the population 44% were using AED supplementary. Conclusion:  In our study, the incidence of early and late PTS is comparable to the other studies. The non-judicious use of the anti-epileptic drug is common in our country which leads to an increase in the risk of drug resistance and cost-intensive for poor patients in developing countries as prophylactic and excessive use of anti-epileptics does not affect the PTE

Outcome of Laminoplasty in Patients with Multilevel Cervical Myelopathy

Objective: To determine the outcome of surgical intervention in the form of laminoplasty in the patients with multilevel cervical myelopathy. Material and Methods: Descriptive case series, was conducted at NS-I, PINS, Lahore for 6 months. The patients were included through non probability consecutive sampling that fulfilled inclusion criteria. All of the patients were assessed using JOA score before and after 2 months of surgery. General characteristics, including age, gender, other medical conditions and other risk factors were assessed prior to surgery. The total number of 35 patients was included with expected JOA percentage recovery rate of 75% + 21% after the procedure. Results: In this study 35 total patients were enrolled. The mean age was 55.68 + 9.92 years. Total number of male patients were 23 (65.71), while the female was 12 (34.29). The mean duration of degenerative cervical myelopathy was 3.90 + 1.3 months. The mean pre op value of JOA score was 7.08 + 2.7 (4 – 10) for the patients. The mean post op score was 13.00 + 2.30 (9 – 17). The mean recovery value calculated at two month interval was 62.12 + 17.39 (38.46 – 100). Statistically, there was a significant difference of outcome of pre and post op value of JOA scores i.e., p value = 0.00. Conclusion: Our study determined that, the open door laminoplasty is an effective and reliable technique with good outcome in the treatment of multi-level degenerative cervical spine myelopathy patients.&nbsp

Endonasal Endoscopic Repair of Cerebrospinal Fluid Leaks

Objective: To assess the outcome of Endonasal Endoscopic Repair of Cerebrospinal Fluid LeaksMethods and Materials: This study was conducted from July 2013 to October 2014 at the department of Neurosurgery, PGMI, Lahore General Hospital, Lahore. A total of 20 patients were included in this study of both gender (male and female) and in the age range of 15 – 65 years. All the patients undergone Endonasal Endoscopic with the use of a Karl Stortz rigid endoscope of 0º and 30º with a 4mm diameter. All of them were followed up for recurrence of CSF leak and any postoperative complication.Results: Out of 20 patients, there were 08 (40%) males and 12 (60%) female patients. Their age ranged from 15 – 65 years. The maximum numbers of patients were in their third and fourth decade of life. The cause of CSF leak was spontaneous in 11(55%), iatrogenic in 5 (25%) and traumatic in 4 (20%) of cases. In 13 (65%) patients, CSF rhinorrhea was from right nostril and in 7 (35%) patients left side was affected. Endonasal Endoscopic CSF repair was done in all patients and was successful in 18 (90%) of patients. Two patients (10%) presented with recurrence of CSF leak in which one was successfully re-operated endoscopically and other undergone transcranial approach. Overall the success rate was 95% in our study. Only one patient complicates with meningitis postoperatively which was resolved with antibiotics.Conclusion: The repair of the CSF rhinorrhea by Endonasal Endoscopic surgery is minimal invasive, safe, effective and is a valid alternative to the cranial approach. Abbreviations: CSF: Cerebrospinal Fluid. MRI: Magnetic Resonance Imaging

Single Burrhole Craniostomy with Subdural Placement of Foley Catheter for Drainage of Chronic Subdural Hematoma

Objective:  Chronic subdural hematoma (CSDH) is a common neurosurgical condition of the elderly. The lack of consensus over a single standard surgical procedure for the management of CSDH urges neurosurgeons to evaluate different techniques in terms of a better outcome. Material & Methods:  In this prospective study forty cases of CSDH who had undergone single burr-hole craniostomy and subdural placement of Foley catheter were analyzed. The observations were made concerning clinical, radiological findings, postoperative complications, and mortality rate. Results:  The study included 26 males and 14 females with a mean age of 67 years. The most common presenting symptom was hemiparesis (n=18, 45%). Recurrent hematoma and recurrent evacuation rate was 10%. There was no case of newly developed postoperative seizures, pneumocephalus, intracranial hemorrhage, and wound infection. The mortality rate during the study was 0.0%. The mean Glasgow outcome score (GOS) at the time of discharge was 4.8. Conclusion:  We concluded that single burr-hole evacuation of CSDH with Foley catheter placement appears to be an effective procedure with a significant reduction in postoperative pneumocephalus. Factors such as sudden decompression of hematoma, the air in the subdural cavity, misplacement of drainage tubes, and damage to blood vessels during surgery can be reduced with this technique

Pattern and Outcome of TBI in Children: An Observational Study at the Children Hospital Lahore

Objective:  TBI is one of the leading causes of mortality. To prevent these deaths and injuries epidemiological evidence is required in individual areas. The study aims to understand the common causes of TBI in children in a localized area of Pakistan. Material and Methods:  This is a descriptive study that enrolled 720 children with head injuries aged 0 to 14 years from September 2021 to June 2022 at UCHS/CHL. Demographic variables like age and gender were noted. Moreover, presenting features of the wound/injury, the cause behind the injury, the severity of the wound, as well as operative procedures that were undertaken, were all recorded. Results:  Mean age of the children was 5 years. Most of them were boys (69.25%). Many of the head injuries were caused due to falls (78.94%) followed by RTA (20.7%). 62.32% of the patients arrived via ambulance. The mortality rate among severe head injury was 65.09%, moderate head injury was 26.31% and mild head injury was 8.52%. It was observed favorable outcomes were noted in patients who presented to the hospital within four hours of injury. (The p-value is .0026). Conclusion:  Head injuries among children in Pakistan are primarily due to falls and road accidents. There is a need for betterment in the architecture of housing and road traffic management to prevent TBI-related mortalities. Awareness and logistics need to be provided for the quick transfer of patients with trauma to neurosurgical emergencies