Short-Term Complications of Microscopic Trans Nasal Transsphenoidal Pituitary Adenomectomy

Background/Objective:   The commonest of pituitary gland tumors is pituitary adenoma which may be excised transcranially or trans nasal trans sphenoidal using either microscope or endoscope, in this study, the microscope was used. The objective was to see the short-term outcome of patients after microscopic transnasal trans-sphenoidal pituitary adenomectomy. Material & Methods:  This was a descriptive prospective study carried out from July 2019 to July 2021. 80 cases were included. All patients were investigated by contrast brain MRI, hormonal assay for pituitary gland & visual perimetry. Patients were evaluated for complications at 48 hours and 7 days. Results:  Mean age of the study population was 41.78 ± 11.75 years. There were 61 (76%) men & 19 (24%) women. 55 (68.8%) patients had functioning and 25 (3.3%) patients had nonfunctioning adenoma. Among 33 (41.3%) patients size of the adenoma was < 0.9 cm and 47 (58.8%) patients had adenoma > 1.0 cm. 12 patients had CSF leaks within 48 hours of surgery and 5 had a persistent leak on the 7th day. No statistically significant association was seen between age, gender, and size of adenoma and persistent CSF leak (P > 0.05). Diabetes insipidus was found in 9 patients. 3 had post-operative hematoma, 01 patient had meningitis and 2 patients died. Conclusion:  microscopic transnasal trans-sphenoidal surgery is a safe procedure yet associated with significant complications

Far Lateral Transcondylar Approach for Anterior Foramen Magnum Lesions

Objective:  To study the efficacy and safety of far-lateral transcondylar approach for anterior foramen magnum lesions with early experience at our Institute. Material and Methods:  We treated six patients, with lesion anterior to the foramen magnum and posterior to the brainstem and cervical cord in a period of 2 years, March 2017 to March 2018.Initial assessment was made by history and examination followed by CT scan and contrast MRI. All were treated using far-lateral transcondylar approach. Result:  Among six patients, there were two were male and four were female. Three of these patients had a meningioma while two patients had neurofibromas and one clival chordoma. Total excision was achieved in five neoplastic cases, while subtotal excision was done in one case. There were no fresh postoperative deficits in any of the other patients. One patient had an unexplained sudden cardiorespiratory arrest 18h after the surgery and succumbed. One patient had cerebrospinal fluid (CSF) discharge from the wound, which was satisfactorily managed by lumber CSF drainage. Conclusion:  This approach provides an excellent approach to lesions located anterior to foramen magnum posterior to the brainstem and upper cervical cord. Gross total excision of these benign and malignant lesions is safely possible through this approach. Keywords:  Craniovertebral Junction, Far-Lateral Transcondylar Approach, Anterior Foramen Magnum, Brain Stem, Chordoma

Clinical Outcome of Cortical Venous Thrombosis in Stroke Patients at a Tertiary Care Hospital of Southern Punjab

Objective:  This study was determined to find out the clinical Outcome of Cortical Venous Thrombosis (CVT) in Stroke patients at a Tertiary Care Hospital of Southern Punjab. Material & Methods:  A total of 100 patients with cortical venous thrombosis were included in this descriptive case series study, which was conducted at Department of Neurology, Nishtar Hospital Multan. Outcome of patients in terms of partial recovery or complete recovery, any recurrence, any complication, indication for Surgery and any disability in terms of focal deficit, prolonged hospital stay and Mortality was followed. Results:  Our study included a total of 100 patients with cortical venous thrombosis (CVT), 35 (35%) were male and 65 (65%) were female patients with their mean age was 37.69 ± 16.52 years, ranging from 20 – 83 years (51.37 ± 17.44 in males versus 30.32 ± 10.15 years for females). Headache was noted in 80%, focal deficit in 57%, nerve palsy in 30%, coma in 22% and disability was noted in 35%. Partial recovery was noted in 65%, whereas complete recovery was noted in 35% while, complications were noted in 12 (12%) of these patients with CVT. Conclusion:  Cortical venous thrombosis was more prevalent in females in their younger age groups and it was associated with poor prognosis as high frequency of partial recovery was noted in our study. Keywords:  Cortical venous thrombosis, Stroke, headache, recovery, outcome

Chiari Malformation with and without Syringomyelia: Surgical Technique and Outcome in 88 Adult Patients

Objective:  This study identified the relationship between posterior fossa craniectomy, expansion neuroplasty, and radiological appearances in patients with Chiari malformation with and without clinical syringomyelia with the surgical outcomes in an attempt to correct the lesion. Materials & Methods:  Eighty-eight patients with Chiari malformation (CM) were included in the study where 70 had associated syringomyelia. All underwent posterior fossa craniotomy, expansion duroplasty without fiddling with cerebellar tonsils. Patients were evaluated at 1 month, 3 months, and 12 months. The MRI studies were done at 12 months when symptomatic relief and radiological findings were evaluated and matched. Results:  Most of the patients were young adults between the age range of 25 – 40 years. The most common complication was pseudomeningocele (5.68%) formation followed by CSF leak (4.54%). Patients with a longer history of Chiari malformation or syrinx-related symptoms and signs had partial relief in symptoms and signs. The poor outcome as expected was seen in patients with atrophic changes in upper limbs and hypertonia in lower limbs, especially in patients with loss of joints position sense and poor balance. Patients showed maximum improvement in headaches both suboccipital as well as generalized. Syringomyelia was decreased in size in 49 patients and remained unchanged in 21.  Dysesthesias were improved in 31 patients. Conclusion:  Clinical improvement was related to the expansion of the posterior fossa and subarachnoid cistern and reduction in the size of the syrinx. Surgical decompression of the posterior fossa should create adequate space for its contents and reduce the syrinx cavity. The relationship between symptomatic improvement and radiological findings is not always linear. Keywords:  Chiari Malformation, Tonsillar Herniation, Syringomyelia, Duroplasty

Lipoma at Conus Medullaris without Spinal Dysraphism causing Neurological Deficit: A Rare Occurrence

It's uncommon to have an intradural lipoma without spinal dysraphism. The majority are asymptomatic, however, neurological impairments might occur. For the past six months, a 35-year-old man had been experiencing growing weakening in both lower limbs. The L1 intradural space-occupying lesion was detected during a clinical examination and radiological workup. The patient underwent surgery to address a worsening neurological impairment. The patient had fully recovered neurologically after a six-month follow-up. If the neurological damage is progressive, intradural lipomas should be surgically removed. The surgical treatment produces positive results

Outcomes of Cranioplasty after Craniectomy

Objective:  Craniectomy is a widely used procedure in neurosurgery that results in more cranioplasties to repair skull defects. The complication rate after cranioplasties seems to be higher than elective craniotomies so this study was conducted to determine the outcome of cranioplasty after craniectomy. Materials & Methods:  The patients included in this study had craniectomy and cranioplasty for any indication. Patients included had variables, such as age, sex, underlying pathology, craniectomy and cranioplasty dates, the material used for cranioplasty (autologous bone or methyl methacrylate), and methods of cranioplasty flap fixation (sutures or titanium plates and screws) follow up period and complications. Results:  It was concluded that patients in the age group of 41 – 60 years (5 cases), males (7 cases), cranioplasty performed after 6 months (5cases) with autologous bone graft (8cases) were associated with more complications. Conclusion:  The overall rate of complications associated with cranioplasties is not negligible, however, early cranioplasty in young patients with the use of polymethyl methacrylate may be associated with less complication rate. Keywords:  Decompressive, Craniectomy, Cranioplasty, Autologous, Polymethyl Methacrylat

Multidisciplinary Management and Outcome of Intradural Extramedullary Spinal Tumors

Introduction/Objective:  About fifteen percent of the primary CNS tumors are intraspinal. About two-thirds of tumors are intradural extramedullary (IDEM). This study was conducted to review the outcome of operative management of intradural extramedullary tumors in correlation with the factors, both clinical & histopathological, influencing the neurology of patients & prognosis. Materials and Methods:  It was a multicenter study including 42 patients conducted from December 2018 to December 2020. All patients were diagnosed by MRI with and without contrast. Patients were surgically treated & analyzed for clinical features i.e., pain by visual analog scale (VAS) & neurology by modified McCormick scale both preoperatively & post-operatively. Clinical features & outcomes were correlated with tumor size & histopathology. p-value < 0.05 was considered significant. Results:  This study included 42 cases. The most common diagnosis was schwannoma (76.19%). The average intradural space occupied at presentation was 82%. The most common location was dorsal (90.4%). The visual analog score for pain (VAS) improved in all patients post-operatively from 7 ± 1.9 to 2 ± 0.8 (p = 0.003) & modified McCormick scale from 3.0 ± 1.3 to 2.0 ± 1.0 (p = 0.005). The preoperative symptoms were correlated with the only size of the tumor occupying the intradural space (VAS p = 0.021, modified McCormick scale p = 0.018). Conclusion:  All the tumors excised showed some improvement in neurological status. Therefore, all patients diagnosed with IDEM should be operated on even if present with prolonged symptoms or severe neurological compromise. Keywords:  Intradural Extramedullary, Meningioma, Schwannoma, Intraspinal

Predictors of Surgical Outcome Following Cerebral Contusion in Severe Head Injuries

Objective:  There are controversies regarding the management of Cerebral Contusion. The study sought to identify parameters influencing the surgical outcome of individuals suffering from a brain contusion. Methods:  A quasi-experimental study was conducted at the Department of Neurosurgery, Mayo Hospital Lahore, and 37 patients were included. The information on the mode/mechanism of injury, time of presentation, clinical presentation, and contusion type/location was collected. GCS (at 1st, 2nd and 6th weeks) and GOS were used for the neurological assessment of pre-operative and post-operative status. Results:  The average age of presentation was 42.57 years. There were 21.6% female and 78.4% male patients. 64.9% presented with road traffic accidents. 4% of patients presented to the hospital within 12 hours of injury, 16.2% between 12 to 24 hours, and 5.4% between 24 to 48 hours. 29% had seizures and upgoing plantar. 18% had hemiparesis or hemiplegia. Light reflex was absent in 40.5% of patients. The GCS kept improving postoperatively. GCS at admission was averaging 8 which improved to 10, 12, and 13 after surgery. The presenting mean GCS at 1st-week, 2nd-week, 6th-week, and mean GOS at 30th PAD. Counter coup injury improved to 15/15 right in 1st week. Mean GOS was 5 at 30th PAD. The most improvement was seen in the frontoparietal, temporoparietal, and fronto-temporo-parietal locations. The mean GOS at 30th PAD was 4. Conclusion:  The outcome following cerebral contusion depends upon the initial presenting GCS and GOS. Therefore, the better the presenting GCS and GOS better is the prognosis of the patient

Normal Pressure Hydrocephalus: Selection of Patients for Shunt Placement

Objective: To determine the criteria in our setup, for patients with normal pressure hydrocephalus (NPH), based on clinical and radiological findings.Material and Methods: This is multiple center study, including departments of Neurosurgery at LGH, Lahore / KEMU, Lahore. Over 25 years, 240 patients were included purely on clinical criteria of poor memory, sphincter loss, gait apraxia and Evan’s ratio ≥ 0.30 on CT or MRI. All patients had shunting procedures.Results: Hundred and ninety patients were improved and all of them had significant reduction in Evan’s ratio i.e. ≥ 0.06. Only 10 patients had infection out of whom 8 lost to follow up while 2 had shunt revision.Conclusion: Shunting procedures especially VP shunt shows good results if selection is stringent and no co-morbidity is associated