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   2013| July-September  | Volume 8 | Issue 3  
    Online since November 20, 2013

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Recurrent lumbar disc herniation: A prospective comparative study of three surgical management procedures
Ayman A El Shazly, Mohammed A El Wardany, Ahmad M Morsi
July-September 2013, 8(3):139-146
DOI:10.4103/1793-5482.121685  PMID:24403956
Context : The optimal surgical treatment of recurrent lumbar disc herniation is controversial. Aim: To compare prospectively the clinical outcomes of surgical treatment of recurrent lumbar disc herniation by three different methods; discectomy alone, discectomy with transforaminal lumbar interbody fusion (TLIF), and diecectomy with posterolateral fusion (PLF), regardless of the postoperative radiological findings. Study Design: This is a prospective, randomized, comparative study. Materials and Methods: This is a prospective, randomized, comparative study on 45 patients with first time recurrent lumbar disc herniation. Patients were evaluated clinically by using the criteria of the Japanese Orthopedic Association's evaluation system for low back pain syndrome (JOA score). The patients were classified into three groups: Group A; patients who had revision discectomy alone, group B; patients who had revision discectomy with TLIF, and group C; patients who had revision discectomy with PLF. The mean follow-up period was 37 (±7.85 STD) months. Results: The mean overall recovery rate was 87.2% (±19.26 STD) and the satisfactory rate was 88.9%. Comparison between the three groups showed no significant difference with regard to the mean total postoperative JOA score, recovery rate, and satisfactory rate. However, the postoperative low back pain was significantly higher in group A than that of group B and C. Two patients in group A required further revision surgery. The incidences of dural tear and postoperative neurological deficit were higher in group A. The intraoperative blood loss and length of operation were significantly less in group A. The total cost of the procedure was significantly different between the three groups, being least in group A and highest in group B. There was no significant difference between the three groups with regard to the length of postoperative hospital stay. Conclusion: Revision discectomy is effective in patients with recurrent lumbar disc herniation. Fusion with revision discectomy improves the postoperative low back pain, decreases the intraoperative risk of dural tear or neural damage and decreases the postoperative incidence of mechanical instability or re-recurrence. TLIF and PLF have comparable results when used with revision discectomy, but PLF has significantly less total cost than TLIF.
  4,612 906 33
Cisternostomy: Replacing the age old decompressive hemicraniectomy?
Iype Cherian, Ghuo Yi, Sunil Munakomi
July-September 2013, 8(3):132-138
DOI:10.4103/1793-5482.121684  PMID:24403955
Backround: Practical scenario in trauma neurosurgery comes with multiple challenges and limitations. It accounts for the maximum mortality in neurosurgery and yet the developing countries are still ill-equipped even for an emergency set-up for primary management of traumatic brain injuries. The evolution of modern neurosurgical techniques in traumatic brain injury has been ongoing for the last two centuries. However, it has always been a challenge to obtain a satisfactory clinical outcome, especially those following severe traumatic brain injuries. Other than the well-established procedures such as decompressive hemicraniectomy and those for acute and or chronic subdural hematomas and depressed skull fractures, contusions etcetera newer avenues for development of surgical techniques where indicated have been minimal. We are advocating a replacement for decompressive hemicranictomy, which would have the same indications as decompressive hemicraniectomy. The results of this procedure has been compared with the results of decompressive hemicraniectomy done in our institution and elsewhere and has been proven beyond doubts to be superior to decompressive hemicraniectomy. This procedure is elegant and can replace decompressive hemicraniectomy because of low morbidity and mortality. However, there is a steep learning curve and the microscope has to be used. Materials and Methods: Based on the clinical experience and observation of acute neurosurgical service in tertiary medical centers in a developing country, the procedure of cisternostomy in the management of trauma neurosurgery have been elucidated in the current study. The study proposes to apply the principles of microvascular surgery and skull base surgery in selected cases of severe traumatic brain injuries, thus replacing decompressive hemicraniectomy as the primary modality of treatment for indicated cases. Conclusion: Extensive opening of cisterns making use of skull base techniques to approach them in a swollen brain is a better option to decompressive hemicraniectomy for the same indications.
  4,301 1,016 18
Success rate of endoscopic third ventriculostomy in infants below six months of age with congenital obstructive hydrocephalus (a preliminary study of eight cases)
Ahmed Z. M. Zohdi, Ahmed M El Damaty, Khaled B Aly, Ehab A El Refaee
July-September 2013, 8(3):147-152
DOI:10.4103/1793-5482.121686  PMID:24403957
Aim: In this study, we were assessing the outcome of Endoscopic Third Ventriculostomy (ETV) in infants below six months of age in cases of congenital obstructive hydrocephalus. Materials and Methods: The study was done prospectively on eight cases of obstructive hydrocephalus in infants younger than six months of age to assess the success rate of ETV as a primary treatment for hydrocephalus in this age group; in cases of evident failure, a ventriculo-peritoneal (VP) shunt was applied. Results: Despite eliminating the factors suggested as causes of ETV failure in infants below six months; the type, as with the communicating hydrocephalus, the thickness of the third ventricular floor, history of previous intracranial hemorrhage or central nervous system infection, still the success rate did not exceed 12.5%. Conclusions: The complication rate following ETV was low in comparison to the high frequency (20-80%) and seriousness of the possible postoperative complications following VP shunt with a significant decrease in the quality of patients' lives. Hence the decision-making as well as the parental counselling were in a trial to estimate the ETV success or the need to perform a shunt in the treatment of obstructive hydrocephalus.
  3,567 447 8
Unruptured anterior communicating artery aneurysms presenting with seizure: Report of three cases and review of literature
Akshay Patil, Girish R Menon, Suresh Nair, Akshay Patil, Girish R Menon, Suresh Nair
July-September 2013, 8(3):164-164
DOI:10.4103/1793-5482.121693  PMID:24403964
Aneurysms generally present with bleed and epileptogenic aneurysms are rare. Unruptured epilpetogenic anterior communicating artery aneurysms are extremely rare and anecdotal. We present three patients with unruptured anterior communicating artery aneurysms who presented with seizures and were surgically managed. Seizure might be related to the large size, presence of thrombus, microbleeds and surrounding gliosis. We suggest that large thrombosed anterior communicating artery aneurysms should be considered in the differential diagnosis of patients presenting with late onset of seizure and having a suprasellar lesion on imaging. Surgical clipping offers a fair chance of seizure freedom in selected patients.
  3,632 263 7
Effect of surgical clipping versus endovascular coiling on recovery from oculomotor nerve palsy in patients with posterior communicating artery aneurysms: A retrospective comparative study and meta-analysis
SA Khan, A Agrawal, CE Hailey, TP Smith, S Gokhale, MJ Alexander, GW Britz, AR Zomorodi, DL McDonagh, ML James
July-September 2013, 8(3):117-124
DOI:10.4103/1793-5482.121671  PMID:24403953
Background: Oculomotor nerve palsy (OMNP) is a well-recognized complication of posterior communicating artery (PCOM) aneurysms. Only a few comparative studies have assessed the effect of clipping versus coiling on recovery from OMNP in PCOM aneurysms. A retrospective review and meta-analysis was conducted to assess the relationship between PCOM aneurysm treatment and OMNP. Materials and Methods: Medical records of all patients presenting between January 2000 and February 2013 with intracranial aneurysm were searched. All patients with OMNP secondary to PCOM aneurysm were included for analysis. Patients undergoing surgical clipping or endovascular coiling were compared with respect to complete resolution of OMNP after aneurysm surgery (i.e., primary outcome). A meta-analysis of published studies of OMNP associated with PCOM aneurysm was performed after a MEDLINE search. Results: Seventeen patients with OMNP secondary to PCOM aneurysms met the inclusion criteria. Surgical clipping (seven of eight patients, or 87.5%) resulted in greater complete resolution of OMNP compared with endovascular coiling (four of nine patients, or 44.4%), P = 0.13. A meta-analysis of similar studies revealed that complete resolution of OMNP was more commonly associated with surgical clipping (36 of 43 patients, or 83.7%) than with endovascular coiling (29 of 55 patients, or 52.7%), yielding an adjusted odds ratio (OR) of 6.04 [confidence interval (CI) =1.88-19.45, P = 0.003]. Multivariate analysis found that the degree of pre-operative OMNP (OR = 0.07, CI = 0.02-0.28, P = 0.001) and surgical clipping (OR = 6.37, CI = 1.73-23.42, P = 0.005) were significant factors that affected the complete recovery of OMNP. Conclusion: Complete recovery of OMNP with PCOM aneurysms is more commonly associated with surgical clipping than with endovascular coiling. Also, the degree of pre-operative OMNP and the treatment modality are significant factors that affect the complete recovery of OMNP.
  3,089 545 20
Hemorrhagic colloid cyst: Case report and review of the literature
Batuk Diyora, Naren Nayak, Sanjay Kukreja, Alok Sharma
July-September 2013, 8(3):162-162
DOI:10.4103/1793-5482.121689  PMID:24403960
Colloid cysts are cystic lesions located at the anterior part of third ventricle, close to foramen of Monro and contain colloid material. Hemorrhage in a colloid cyst is very rare. On literature review, we found only six cases of hemorrgic colloid cyst; among them, four were diagnosed at postmortem examination. We report a rare case of a hemorrhagic colloid cyst in a young lady who presented with sudden onset severe headache and vomiting. Computed tomography (CT) scan showed isodense lesion located at foramen of Monro with hyperdense areas suggestive of hemorrhage with foraminal obstruction. The lesion was not enhancing on contrast. Magnetic resonance imaging (MRI) brain revealed a well-defined cystic mass lesion located at the foramen of Monro which was hyperintense on T1 and hypointense on T2-weighted images. Excision of the colloid cyst was performed which revealed hemorrhagic clot instead of colloid material. Histopathological examination revealed a colloid cyst with hemorrhage. We believe that this is the first such reported case of successful clinical outcome following early diagnosis and excision of a hemorrhagic colloid cyst in an adult.
  2,568 349 7
Large primary intraorbital hydatid cyst in elderly
Veeresh U Mathad, Hukum Singh, Daljit Singh, Manoj V Butte, M Kaushik, Veeresh U Mathad, Hukum Singh, Daljit Singh, Manoj V Butte, M Kaushik
July-September 2013, 8(3):163-163
DOI:10.4103/1793-5482.121691  PMID:24403962
We report a case of solitary, primary intraorbital hydatid cyst in a elderly female aged 80 years who presented with nontender, nonpulsatile proptosis of left eye with diminution of vision. MRI scan of the head and the orbits, revealed a retro-bulbar cyst. Surgical excision was performed by employing a lateral orbitotomy approach. Histopathology report confirmed hydatid cyst.
  2,628 192 -
Optimal invasive key-hole neurosurgery with a miniaturized 3D chip on the tip: Microendoscopic device
Patra Charalampaki, Alhadi Igressa, Mehran Mahvash, Ioannis Pechlivanis, Bernhard Schick
July-September 2013, 8(3):125-131
DOI:10.4103/1793-5482.121681  PMID:24403954
Objective: The goal of the performed study was to evaluate the possibility of a three-dimensional endoscope to become a combined microscope-endoscope device in one. We analyzed the ergonomy of the device, the implementation into the surgical workflow, the image quality, and the future perspectives such devices could have for the next generation of neurosurgeons. Materials and Methods: Within 6 months, 22 patients (10 male, 12 female, 20-65 age) underwent surgery in neuroaxis using the new 3D-microendoscope (ME). The new 3D-ME has (a) the ability to visualize the surgical field from out- to inside with all advantages offered by a microscope, and in the same moment, (b) its design is like a small diameter endoscope that allows stereoscopic views extracorporal, intracorporal, and panoramic "para-side" of the lesion. Results: In general, transcranial 3D-"microendoscopy" was performed in all patients with high-resolution 3D quality. No severe complications were observed intra- or postoperatively. With the addition of depth perception, the anatomic structures were well seen and observed. Conclusion: The 3D-microendoscopy is a very promising surgical concept associated with new technological developments. The surgeon is able to switch to a modern visualization instrument reaching the most optimal surgical approach without compromising safety, effectiveness, and visual information.
  2,515 300 6
Demographic and clinical profile of patients with brain metastases: A retrospective study
Animesh Saha, Sajal Kumar Ghosh, Chhaya Roy, Krishnangshu Bhanja Choudhury, Bikramjit Chakrabarty, Ratan Sarkar
July-September 2013, 8(3):157-161
DOI:10.4103/1793-5482.121688  PMID:24403959
Context: Brain metastases are the most common type of intracranial neoplasm, with the total number outnumbering primary brain tumors by a ratio of 10:1 and occur in about 25% of cancer patients. However, controversies exist regarding demographic and clinical profile of brain metastases. Aims: The purpose of this study was to analyze retrospectively the demographic and clinical profile of patients with brain metastases. Settings and Design: Retrospective, single institutional study. Materials and Methods: A retrospective study of 72 patients with brain metastasis was carried out from November 2010 to October 2012. The data pertaining to these patients was entered in a standardized case record form. These include History; clinical examination and other investigations including computed tomography/magnetic resonance imaging scan of the brain. Statistical Analysis: A statistical analysis was performed on the data collected using the MedCalc version 11. Results: Brain metastases were more common in male and occur in 6 th decade of life mostly. There was no relationship of occupation or socio-economic status with the incidence of brain metastases. Carcinoma lung was the most common primary giving rise to brain metastases followed by breast. Adenocarcinoma accounts for most common histology of the primary that give rise to metastases. Multiple metastases were more common than the single group. Supratentorial lesions were more common than infratentorial lesions. Among them, parietal lobe was the most common site of involvement. Conclusions: The present study highlights that the incidence of brain metastasis is common in elderly population and mostly due to primary lung. Adenocarcinoma was the most common histology of primary. Majority of lesions has been observed at parietal lobe.
  2,381 431 11
Percutaneous pedicle screw placement in the thoracic spine: A cadaveric study
Carolyn A Hardin, Shahid M Nimjee, Isaac O Karikari, Abhishek Agrawal, Richard G Fessler, Robert E Isaacs
July-September 2013, 8(3):153-156
DOI:10.4103/1793-5482.121687  PMID:24403958
Study Design: A cadaveric study to determine the accuracy of percutaneous screw placement in the thoracic spine using standard fluoroscopic guidance. Summary of Background Data: While use of percutaneous pedicle screws in the lumbar spine has increased rapidly, its acceptance in the thoracic spine has been slower. As indications for pedicle screw fixation increase in the thoracic spine so will the need to perform accurate and safe placement of percutaneous screws with or without image navigation. To date, no study has determined the accuracy of percutaneous thoracic pedicle screw placement without use of stereotactic imaging guidance. Materials and Methods: Eighty-six thoracic pedicle screw placements were performed in four cadaveric thoracic spines from T1 to T12. At each level, Ferguson anterior-posterior fluoroscopy was used to localize the pedicle and define the entry point. Screw placement was attempted unless the borders of the pedicle could not be delineated solely using intraoperative fluoroscopic guidance. The cadavers were assessed using pre- and postprocedural computed tomography (CT) scans as well as dissected and visually inspected in order to determine the medial breach rate. Results: Ninety pedicles were attempted and 86 screws were placed. CT analysis of screw placement accuracy revealed that only one screw (1.2%) breached the medial aspect of the pedicle by more than 2 mm. A total of four screws (4.7%) were found to have breached medially by visual inspection (three Grade 1 and one Grade 2). One (1.2%) lateral breach was greater than 2 mm and no screw violated the neural foramen. The correlation coefficient of pedicle screw violations and pedicle diameter was found to be 0.96. Conclusions: This cadaveric study shows that percutaneous pedicle screw placement can be performed in the thoracic spine without a significant increase in the pedicle breach rate as compared with standard open techniques. A small percentage (4.4%) of pedicles, especially high in the thoracic spine, may not be safely visualized.
  2,305 477 6
Grave's disease with transverse and sigmoid sinus thrombosis needing surgical intervention
Banumathy Srikant, Srikant Balasubramaniam, Banumathy Srikant, Srikant Balasubramaniam
July-September 2013, 8(3):162-162
DOI:10.4103/1793-5482.121690  PMID:24403961
Thrombosis of venous sinuses associated with thyrotoxicosis is rare, and isolated transverse and sigmoid sinus thrombosis is rarer and reported only once previously. We present a case of Graves disease, who suffered unilateral sigmoid and transverse sinus thrombosis with intracranial hemorrhage. A 42-year-old female, a diagnosed case of Graves disease, presented to us with headache, drowsiness, and hemiparesis. Computed Tomography revealed a large right temporo-parieto-occipital venous infarct. The patient needed surgical intervention in the form of decompressive craniotomy following which she improved, and on follow-up is having no deficits. Thrombophilia profile showed a low Protein S and Anti thrombin III (AT III) levels. Deranged thrombophilia profile in combination with the hypercoagulable state in thyrotoxicosis, most likely precipitated the thrombotic event. Timely surgical intervention can be offered in selective cases with a good clinical outcome.
  1,819 270 2
Armoured brain of unknown etiology
Puneet Kumar Goyal, Daljit Singh, Hukum Singh, Jaya Dubey, Monica Tandon, Puneet Kumar Goyal, Daljit Singh, Hukum Singh, Jaya Dubey, Monica Tandon
July-September 2013, 8(3):165-165
DOI:10.4103/1793-5482.121695  PMID:24403965
Armoured brain is a rare condition where dense calcification occurs over the brain. It can result in mass effect and raised intracranial pressure. Most often, it happens due to trauma, subdural effusion, infection, or after VP shunt. There is controversy in its treatment. Most published literature does not support removing the calcification. We describe a rare case of idiopathic chronic calcified subdural hematoma with relatively short history which was successfully treated by microsurgical removal of calcification over the brain. This resulted in complete expansion of the brain with relief in symptoms.
  1,771 244 4
Atlanto-axial dislocation associated with anomalous single vertebral artery and agenesis of unilateral internal carotid artery
Anant Mehrotra, Jayesh Sardara Chunnilal, Kuntal Kanti Das, Arun Srivastava, Raj Kumar, Anant Mehrotra, Jayesh Sardara Chunnilal, Kuntal Kanti Das, Arun Srivastava, Raj Kumar
July-September 2013, 8(3):164-164
DOI:10.4103/1793-5482.121692  PMID:24403963
We report a case of an anomalous single midline vertebral artery (VA) in a case of atlanto-axial dislocation (AAD). The left VA coursed in the midline at craniovertebral junction as there was no right VA. The left internal carotid artery was also not formed. This was a case report of a 34-year-old male patient who presented with features of high cervical myelopathy. On evaluation, he had fixed AAD. There was inadvertent intra-operative VA injury, which was sealed to control the brisk bleeding to require stenting ultimately. Patient did not survive and expired after 5 days due to brain edema secondary to compromised anomalous intracranial circulation.
  1,224 255 3