White coat hypertension is not a benign entity: a cross-sectional study at a tertiary care hospital in Pakistan

OBJECTIVES: To determine the frequency of White Coat Hypertension in patients undergoing ambulatory blood pressure monitoring at a tertiary care center and to compare ambulatory blood pressure profiles of normotensives, white coat hypertensives and hypertensives.METHODS: A descriptive cross-sectional study was conducted which included all adult patients undergoing ambulatory blood pressure monitoring over a 3-year period. Those patients with incomplete data, less than 85% successful BP readings and inadequate number of daytime and nighttime readings were excluded from the study. The data on ambulatory blood pressure monitoring comprised of demographics, blood pressure, pulse pressure and mean arterial pressure readings at every 30 minutes interval and also a graphical representation of patients\u27 24-hour blood pressure recording. SPSS was used for data analysis. Chi-square test and analysis of variance (ANOVA) was used for qualitative and quantitative variables respectively.RESULTS: A total of 277 patients with a mean age of 48.98 +/- 17.52 years were included. There were 189 (58%) males included in the study. Out of the total, 46 (16.6%) patients had White Coat Hypertension, 59 (21.3%) were Normotensive and 172 (62.1%) had Hypertension. The mean age of Normotensives was 40.80 +/- 14.11 years, White Coat Hypertensives was 37.72 +/- 14.58 years and Hypertensives was 54.80 +/- 16.76 years (

Clinical review of pediatric pilocytic astrocytomas treated at a tertiary care hospital in Pakistan

Abstract Background: Pilocytic Astrocytoma (PA) is a common type of brain tumor in the pediatric population. They have a fairly good prognosis. This study describes PAs in detail, with a focus on the demographic factors, presenting features, management and prognosis, and aims, to identify the negative outcome predictors in our population, which can affect the course of the disease. This article will add to the understanding of PAs from a third world perspective. Methods: The Aga Khan University medical records (1995 – 2007) were reviewed, to study the clinical features, management, and outcome of patients (0 – 15 years) with Pilocytic Astrocytomas (PAs) in our population. After a thorough review of the medical records, all the PAs diagnosed on the basis of histopathology at our Pathology Laboratory, during this period, were included in the study. Results: Twenty-two patients were included with a mean age of 9.25 years. Male-to-female ratio was 1 : 1. The most common presenting feature was a sign of increased intracranial pressure. The most common location was the cerebellum followed by the cerebrum. Fifteen patients underwent maximum surgical resection. Three had recurrence, despite no residual tumor. There were 10 Intensive Care Unit (ICU) admissions and one inpatient mortality. Fifteen patients followed up in the clinic: Eight had recurrence and four underwent repeat surgery (three showed clinical improvement). Hydrocephalus was a predictor of ICU admission. Solid consistency was found to be a marker of recurrence. Conclusion: Pilocytic Astrocytomas are the most common pediatric brain tumors in our population, commonly located in the cerebellum. Complete resection is the best treatment option, but some tumors are aggressive and recurrence is not uncommon. The possible negative outcome predictors are age, source of admission, extent of resection, hydrocephalus, and solid consistency

Tonsillobiventral fissure approach to the lateral recess of the fourth ventricle

OBJECTIVE Surgical access to the lateral recess of the fourth ventricle (LR) is suboptimal with existing transvermian and telovelar approaches because of limited lateral exposure, significant retraction of the cerebellar tonsil, and steep trajectories near brainstem perforator arteries. The goal in this study was to assess surgical exposure of the tonsillobiventral fissure approach to the LR, and to describe the relevant anatomy. METHODS Two formaldehyde-fixed cerebella were used to study the anatomical relationships of the LR. Also, the tonsillobiventral fissure approach was simulated in 8 specimens through a lateral suboccipital craniotomy. RESULTS The pattern of the cerebellar folia and the cortical branches of the posterior inferior cerebellar artery were key landmarks to identifying the tonsillobiventral fissure. Splitting the tonsillobiventral fissure allowed a direct and safe surgical trajectory to the LR and into the cerebellopontine cistern. The proposed approach reduces cervical flexion and optimizes the surgical angle of attack. CONCLUSIONS The tonsillobiventral fissure approach is a feasible and effective option for exposing the LR. This approach has more favorable trajectories and positions for the patient and the surgeon, and it should be added to the armamentarium for lesions in this location

Left Transsylvian-Transinsular Approach for Radiation-Induced Cavernous Malformation: 3-Dimensional Operative Video

De novo cavernous malformation (CM) formation after radiation therapy for brain tumors is well known, but CM formation adjacent to a radiosurgically treated arteriovenous malformation (AVM) is rare.1 This video demonstrates the microsurgical resection of a de novo CM adjacent to a previously treated high-grade AVM and clipping of a middle cerebral artery (MCA) aneurysm. A 70-yr-old male with history of radiosurgery for AVM presented with aphasia and confusion. Preoperative angiography showed complete occlusion of the AVM. MRI showed multiple cystic lesions suspicious for radiation-induced necrosis and CM. IRB approval and patient consent was obtained. A pterional craniotomy was performed with transsylvian exposure of the insula. The radiated feeding arteries were followed to the occluded AVM nidus. A CM was noted deep to this candelabra of the MCA vessels, which were mobilized to access and resect the CM. A small incision was made in this insular cortex underneath the malformation circumferentially freeing it of adhesions. The sclerotic AVM nidus was circumferentially dissected and removed en bloc. Thorough exploration of the resection cavity revealed no residual CM or AVM nidus. Attention was then turned to the M2-MCA bifurcation aneurysm, which was occluded with a straight clip. Postoperative imaging confirmed complete CM resection. The patient recovered from his aphasia. This case demonstrates the management of a radiation-induced de novo CM following treatment of a high-grade AVM. Radiographic follow-up for radiosurgically treated AVM is needed to rule out long-term complications. Bleeding from a de novo CM mimics bleeding from residual AVM nidus, requiring careful angiographic evaluation

To Operate Versus Not to Operate in Low-Resource Settings: Example of Aneurysm Surgery in Rural Iran and Impact of Mastery of Neurosurgical Anatomy

BACKGROUND: Subarachnoid hemorrhage (SAH) has a global incidence of 9/100,000. In low-resource settings, where neurosurgical capacity is diminished through fewer human and technological resources, neurosurgeons may not be prepared to operate on aneurysm cases in emergent situations. We report a patient presented with aneurysmal SAH in rural Iran, creating the dilemma of the will for the neurosurgeon. We discuss the impact of the knowledge of neurosurgical anatomy on the resolution of this dilemma. CASE DESCRIPTION: A 30-year-old female presented with aneurysmal SAH to a remote medical facility in rural Iran. A safe and fast referral to a nearby vascular neurosurgery center was not available. A contrasted computed tomography (the only available imaging modality) revealed a carotid bifurcation aneurysm. The situation was explained to the patient and family, and they decided to proceed with surgery. With the minimum technical radiological and surgical equipment available, the surgeon managed to successfully treat the patient, aided by his mastery of the neurosurgical anatomy. The patient was discharged without any complication. CONCLUSIONS: We highlight the importance of mastery of neurosurgical anatomy, which was critical in achieving a favorable patient outcome. The necessity of developing low-cost platforms to enhance neurosurgical anatomy learning in neurosurgical residency programs of low-resource regions and countries is discussed