Spinal cord injury without radiographic abnormality (SCIWORA) in adults: A report of two cases

Spinal cord injury without any radiographic abnormality (SCIWORA) is rare in adults. We describe here two case reports of adult patients, who presented to us with quadriplegia, following a road traffic accident. Plain radiography and computed tomography (CT) of cervical spine were normal. Hence the patients were diagnosed as cases of adult SCIWORA. However, subsequent magnetic resonance imaging (MRI) of the two patients revealed cervical cord injury in the form of cord contusion and disc protrusion, respectively. Patient with cord contusion was managed medically, whereas the patient with disc lesion was treated with discectomy. Patient treated with discectomy showed marked improvement. Therefore, patients having no osseous injury on X ray and CT scan should have an MRI study done to look for surgically correctable pathology. As in such rare patients of SCIOWRA an early diagnosis and timely intervention is crucial; with MRI playing a pivotal role

Variables that Predict Significant Intracranial Damage in Mild Head Injury

Objective: To identify patients, at risk of intracranial complications, after mild head injury.Study Design: It was an observational study.Place and Duration: Patients received at the emergency department or OPD or referred to Pakistan institute of Medical Sciences, Islamabad were included in the study. Pakistan institute of Medical Sciences is a tertiary care hospital that recruits patients from Punjab and northern areas. The data was collected over a period of six mon-ths from 1st August 2008 till 31st January 2009. A total of 206 patients were included in our study.Methodology: Data were analyzed relating to a consecutive series of 206 patients who presented to the emer-gency department of Pakistan Institute of Medical Sciences, Islamabad. Data was collected through non-pro-bability convenience sampling. Characteristics studied, were age, gender, mode of trauma, level of consciousness and CT scan brain findings.Result: Our study included 206 patients with mild head injury. Their age ranged from 1 to 90 years with a mean age of 32.06 19.86 years. Maximum patients (59 patients 28.6%) were in the age range of 21 – 30 years. Only 34 (16.5%) patients were above 50 years of age and 26 (12.6%) were below the age of 10 years.163 (79%) were males and remaining 43 (21%) were females. 124 (60.2%) were due to road traffic accidents, 62 (30.1%) were due to falls, 18 (8.7%) were assault injuries and 2 (0.9%) were sports injuries. All patients had a GCS score of 13 – 15; with a mean score of 14.35 0.902. Majority of the patients (132 patient, 64%) had a GCS of 15, 14 (6.8%) had a GCS of 14 and 60 (29%) had a GCS of 13. 127 (61.7%) patients presented with vomiting after head injury and 79 (38.3%) patients did not vomit. 49 (23.8%) vomited once and 78 (37.9%) vomited on multiple occasions. CT scan was done without contrast in all patients. It was reported as normal in 68 (33%) patients, 39 (18%) had extradural hematoma, 15 (7.3%) had subdural hematoma, 4 (1.9%) showed intracerebral hemor-rhage, 30 (14.6%) had cerebral contusion, 6 (2.9%) had subarachnoid hemorrhage, 20 (9.7%) had diffuse axonal injury and 9 (11.7%) patients had skull fracture.Conclusion: Our study was conducted to derive and validate a set of criteria that could be used to identify patients with minor head injury in whom CT could be forgone. It concluded that men, in their twenties, suffered from mild head injury, most commonly from a road traffic accident and were more likely to have an intracranial surgical lesion, such as an extra dural haematom

Impact of Time Taken on the Surgical Outcome of Extradural Hematoma in Patients with Road Traffic Accidents

Background: To determine the impact of time taken on the surgical outcome of extradural hematoma in patients with road traffic accidents.Methods: Sixty adult patients with history of road traffic accident with extradural hematoma on axial images of CT scan brain were included. All patients were allocated into three groups with 20 patients in each group. Patients in Group I were those in whom time from the occurrence of trauma to the surgical evacuation of hematoma was < 1 hour, 1 to 6 hours in group II and > 6 hours in group III.Results: In group I, majority (90 %) showed favourable outcome. In group II, 70 % showed favourable outcome. In group III, 50 % showed favourable outcome. Significant association was found between outcome and time of surgery (p<0.05).Conclusions: Frequency of favourable outcome after surgical evacuation was significantly higher in patients in whom surgery was performed within one hour after the trauma (P<0.05)

Cerebellar Tubercular Abscess

Tubercular brain abscess is an uncommon lesion and tubercular cerebellar abscess is rarely reported. Almost all case reports of tuberculous abscess are described in HIVinfected or immunocompromised patients. We report a case of presented with an immunocompetent patient who was diagnosed with probable tuberculous brain abscess of the cerebellum. She complained of headache, neck pain and unsteadiness of gait since two months and associated diplopia on clinical examination. She did not have any history of pulmonary tuberculosis. Diagnosis was made by CT scan/MRI of brain. She responded well to anti tuberculous treatment and her symptoms resolved without any surgical intervention

Role of Intermittent Self Catheterization after Cauda Equina Syndrome Surgery.

Background: To determine the effectiveness andsafety of intermittent self catheterization in caudaequina patients who have lost the bladder control.Methods : In this prospective study patients withsymptoms and signs of cauda equina syndrome, dueto lumbar disc herniation confirmed by relevantMRI ,were included. Emergency surgery wasperformed and post operatively these patients weretaught the technique of intermittent selfcatheterization. After full aseptic measures patientswere asked to sit on the chair and identify themeatus. Catheter was slowly inserted into thebladder,uptil the urine output was obtained.Pressure on the lower abdomen was applied to helpin emptying the bladder. Nelton catheter wasremoved and was kept in a bottle of clean water.After couple of attempts patients learnt to pass thecatheter. Patient was asked and helped to do thisactivity 3 to 4 times a day. The patient wasdischarged from the hospital only when he/she wasconfident enough to catheterize himself/herself.Initially patients were kept on biweekly follow upand later on monthly basis.Results : Majority (86%) continued to undergointermittent self catheterization, but 14% , elderlypatients, experienced insertion difficulty anddiscontinued intermittent self catheterization. Tenpatients (24%) had bacteriuria during the procedure.Epididymitis was seen in 2%. There were no urethralcomplications suggesting that the self-lubricatingNelton catheters are safe and less traumatic.Conclusion: Intermittent self catheterization is asafe, effective treatment and is associated withimproved quality of life in cauda equina syndromepatients

Outcome of Endoscopic Third Ventriculostomy

Background: To study the outcome of endoscopic third ventriculostomy (ETV)Methods: In this observational study an endoscopic third ventriculostomy was applied in patients who suffered from hydrocephaly. The diagnosis of hydrocephalus was determined by  physical, neurological and neuro-radiological criteria. Patients with obstructed hydrocephalus whether congenital or acquired, with a dilated 3rd ventricle were included. Linear incision was given 2cm anterior to the coronal suture in mid pupillary line. Right frontal burr hole is made. For ETV, burr hole is placed on a line joining the foramen of monro and inter-peduncular line. Floor of the thirdventricle was punctured close to or over the dorsum sellae. Membrane was dilated with balloon. Balloon was inflated and subsequently was taken out from puncture site. It ensured easy visibility of basilar artery and its perforators.Result: Age of patients ranged from 06 months to 24 years, with a mean age of 4 years . Fourteen patients had posterior fossa tumour’s with dilated third ventricle, sixty four patients had aqua ductal stenosis, two patients with CSF ascites as complication of ventriculo-peritoneal shunt, eleven patients had blocked lower end of ventriculoperitoneal shunt. Seven patients had CSF leak. Time taken to complete endoscopic third ventriculostomy was from 20 to 40 min as compared to 1 hour to 1.30 hours, taken in a VP shunt. Patients who had ETV performed had a mean hospital stay of 3 days, where as patients in whom a VP shunt was performed stayed in the ward for an average of 5 to 10 days, depending on how eventful the post op period was. The cost incurred to the VP shunt patient who remained admitted for an average of 5 days was between Rupees 16,000 to 25,000, ascompared to Rs: 2000 for the patient who underwent endoscopic third ventriculostomy.Conclusion: Patients of ETV, with less per operative time, had decreased length of stay. ETV also was less expensive to the patient and he did not have to buy the shunt apparatus with less rehospitalization rates, compared to patients who had undergone shunt

Comparison of Decompressive Craniectomy and Multi-Dural Stabs with Decompressive Craniectomy and Open-Dural Flap Method, in the Treatment of Acute Subdural Hematomas

Background: To compare the functional outcome between decompressive craniectomy and multi-dural stabs, with decompressive craniectomy and open-dural flap, in the removal of acute subdural hematomas . Methods : In this randomized controlled trial,  64 patients, with acute sub-dural hematomas were included.  Patients were divided into two groups on the basis of lottery method. All patients gave informed written consent. In group A, all patients were operated upon by multi-dural stab technique and in group B, patients were operated upon by open-dural flap technique. The objective degree of recovery in the patients treated by both craniectomy techniques was assessed by Glasgow Outcome Score (GOS), having maximum of 5 and minimum of 1 score. Favourable outcome was at points 4-5 and Un-favourable at 1-3 points, at 2 weeks. GOS attached as annexure A. Favourable outcome was assessed at 2 weeks according to GOS. Results : The mean age in group-A and group-B was 59.09 ± 9.39 years and 59.56 ± 9.98 years. Males constituted the main in both groups. Mean GOS in group A and in group B, was 3.06 ± 1.24 and 2.69 ± 0.82 respectively. Statistically mean GOS was same in this study groups, p-value 0.159, > 0.05. There were 37.5% patients in group A and 9.4% patients in group B who had favourable results, while in group A and group B, 62.5% and 90.60% patients had unfavourable results. Favourable results were statistically more in group A as compared to group B, p-value =0.008. Conclusion: Treatment of acute subdural hematoma by decompressive craniectomy with multi dural stabs technique has more favourable results (using GOS) than decompressive craniectomy with open-dural flap technique

Playing First-Person Perspective Games with Deep Reinforcement Learning Using the State-of-the-Art Game-AI Research Platforms

Computer games have become one of the most interesting and dynamic research areas of artificial intelligence as computer games are the best testbeds to evaluate and test the theoretical ideas in artificial intelligence before applying them in real-world. The enhancement in computing power, advancement in machine learning particularly deep reinforcement learning, and the evolution of neural networks are allowing the autonomous game agents to perform substantially well that often leave behind human beings by using only the screen raw pixels for making their actions or decisions. In this chapter, we use Deep reinforcement learning in the form of Deep Q-learning under its two variants Deep Q-Network (DQN) and Deep Recurrent Q-Learning Network (DRQN) to control agents in playing the two famous computer games i.e. Doom and Minecraft. We present how to build an implementation of a testbed for such state-of-the-art methods using the ViZDoom, Gym-Minecraft and Microsoft\u27s Malmo platforms. Initially, we present our results on a simplified game scenario(s) from Doom in predicting the enemy positions (game features) with the difference in the performance of the DQN and DRQN in both fully observable Markovian decision process (FOMDP) and partially observable Markovian decision process (POMDP) and claim that the DQN performs better at predicting the enemy positions. Finally, we present results on another game scenario(s) from Minecraft to test and confirm the performance of DRQN in POMDP where unlike other existing works, our proposed architectures outperform the built-in AI agents and human players in predicting the game features with enhanced accuracy