Editorial vol.10(2)

Not Available Bang. J Neurosurgery 2020; 10(1): 1

Unilateral Papillitis as the Initial Presentation of Hemifacial Atrophy: Case Report and Review of Literature

Papillitis is a vision threatening condition, characterized by inflammation of the optic disc which often mimicked the features of papilledema; hence these patients often referred to the Neurosurgeon to exclude any intracranial pathology. This entity is associated with a number of intracranial, as well as extracranial pathologies. Among them, Parry–Romberg syndrome, also known as progressive hemifacial atrophy (PHA) possesses multiple ophthalmologic and neurologic manifestations. Here we report the case of a 14-year-old girl, who presented with the feature of progressive dimness of vision involving the right eye. Thorough physical examination demonstrated features of PHA overlapping with papillitis on fundoscopic examination. The patient treated with steroids, following which there was visual improvement. After evaluation in our facility, she was referred to department of plastic and reconstructive surgery for aesthetic improvement. Bang. J Neurosurgery 2020; 10(1): 97-101

Correlation between Magnetic Resonance Imaging (MRI) Findings with Histological Grading of Patients with Supratentorial Diffusely Infiltrating Astrocytomas

Data regarding the impact of MRI for diagnosis and staging of brain tumors in our population is sparse. Thus, the purpose of this study is to determine the efficacy of MRI in preoperative diagnosis of primary intra-axial brain tumors and to determine its diagnostic accuracy in grading of gliomas in our population, correlated with histopathological (hematoxylin & eosin stain) findings taking as gold standard. There has been extensive works in developed countries regarding the diagnostic effectiveness of MRI. But only a few works have been done in our country. To be very particular, little work has been done regarding the performance tests of MRI regarding histological correlation with gliomas in Neurosurgery Department, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh. So, I have tried to correlate MRI findings with the histopathological (hematoxylin & eosin stain) findings of supratentorial diffusely infiltrating astrocytomas. To evaluate the relationship of Magnetic Resonance Imaging (MRI) findings with histological grading of patients with gliomas, to assess MRI findings of gliomas and to assess histological grading of gliomas. The study was carried out in the Department of Neurosurgery, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh, from March 2015 to August 2016. This study was descriptive type of observational study (Cross sectional study). Study Population were include all the patients with supratentorial gliomas admitted in the department of neurosurgery, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh, during the above mentioned time. All patients were admitted through out patient & emergency department of Neurosurgery, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh, were included in the study after primary screening with inclusion and exclusion criteria. History of the patients were taken with demographic data. General examinations were carried out after admission. Neurological examinations were carried out thoroughly. Grading of gliomaswere done from MRI findings. Histopathologies were done of resected tumour tissues. After ethical clearance for the study from the Department of Neurosurgery and IRB, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh, written informed consents were taken from the patients and/or the legal guardians/responsible family members after completely explaining the procedure and the purpose of the study in easy local language. Patients data were collected in data collection sheets. Every patient was enjoy every right to participate or refuse participation and had the right to withdraw from the study at any time without compromising their medical care. The privacy of the patients were strictly maintained and the patients informations were notdisclosed to any source. The study data were onlyused for the purpose of this scientific study. Data were processed and analyzed using computer software SPSS (Statistical Package for Social Sciences) version 22.Descriptive data presented on categorical scale were expressed as frequencies and corresponding percentages, while the data presented on continuous scale were measured as mean and standard deviation (SD). Correlation between categorical variables were evaluated using Spearman’s rank correlation test. For analytical tests, level of significance was set at 0.05 and p-value <0.05 was considered significant. The summarized informations were then presented in form of tables and figures. For the validity test, sensitivity, specificity, accuracy, positive predictive value and negative predictive value of MRI in detecting the grade of intracranial gliomas were calculated after confirmation of the diagnosis by histopathology. Results: The age range of patients were 18 to 70 years. The peak age incidence were >50 years age group. 75.8% patients were male and 24.2% patients were female. The male to female ratio was 3.12:1. Regarding midline crossing in MRI of brain , 24 (72.7%) patients showed no crossing of midline, 2 (6.1%) patients showed equivocal and 7 (21.2%) patients showed crossed midline. In 4 (12.1%) patients there were mild edema, 12 (36.4%) patients showed moderate edema and 17 (51.5%) patients showed marked edema. 10 (30.3%) patients had well circumscribed lesion, 15 (45.5%) patients had poorly circumscribed lesion and 8 (24.2%) patients had highly infiltrating lesion. 7 (21.2%) patients showed mild mass effect, 18 (54.5%) patients had moderate mass effect and 8 (24.2%) patients had severe mass effect. Necrosis/cystic change of tumor were present in 19 (57.6%) cases. 6 (18.2%) patients showed mild heterogeneity, 22 (66.7%) patients showed moderate heterogeneity and 5 (15.2%) patients showed severe heterogeneity. Definitive haemorrhage showed 5 (15.2%) patients. WHO grading of gliomas by MRI. 17 (51.5%) patients of the gliomas were classified as WHO Grade IV, followed by 9 (27.3%) patients were Grade II and 7 (21.2%) patients were Grade III. WHO grading of gliomas by histopathology. 16 (48.5%) patients of the gliomas were classified as WHO Grade IV, followed by 9 (27.3%) patients were Grade II and 8 (24.2%) patients were Grade III. Out of 33 patients, 09 patients were diagnosed as grade II (Low grade gliomas) by MRI, among them 08 cases were proved as grade II (Low grade glioma) and 01 case was grade III (Anaplastic Astrocytoma) by histopathology. 07 patients were diagnosed as grade III (Anaplastic Astrocytoma) by MRI, among them 05 cases were proved as grade III (Anaplastic Astrocytoma) and 01 case was grade II (Low grade glioma) and 01 case was grade IV (Glioblastoma Multiforme) by histopathology. 17 patients were diagnosed as grade IV (Glioblastoma Multiforme) by MRI, among them 15 cases were proved as grade IV (Glioblastoma Multiforme) and 02 cases were (Anaplastic Astrocytoma) by histopathology. Among 33 patients, 09 patients were diagnosed as low grade gliomas by MRI, among them true positive were in 08 cases and 01 cases were diagnosed as low grade gliomas by MRI but was diagnosed as high grade gliomas by histopathology. This 01 case was false positive. Out of 33 cases of gliomas 24 were diagnosed as high grade gliomas by MRI, among them 23 cases were true negative and 01 case was diagnosed as high grade gliomas by MRI but was proved as low grade gliomas by histopathology. This 01 case was false negative. MRI is accurate in preoperative diagnosis and assessing the characteristics of intracranial gliomas. It is very accurate in assessing the grade of gliomas. Tumor necrosis, irregular margins, mass effect of tumor and peritumoral edema are most important indicators of tumor grade. The present study revealed that there is significant correlation between the MR imaging features and histopathological grading of intracranial gliomas. Bang. J Neurosurgery 2020; 10(1): 67-74

Glucocorticoid In Cytotoxicity Followed by Delayed Edema

Background: Cytotoxicity is the toxicity to cell. Any type of brain oedema producing raised intracranial pressure (ICP) which may be a fatal pathological state. Corticosteroid is contraindicated in cytotoxic brain oedema but in vasogenic oedema, it is beneficial. Cytotoxic oedema in its consequences induces vasogenic oedema where the corticosteroid may helpful. Objectives: To determine the effects of corticosteroid on tertiary vasogenic brain oedema from cytotoxic edema. Methods: Total of 328 patients was diagnosed as brain oedema and they had been first time reported & all were admitted in Combined Military Hospital (CMH) Dhaka, between Jan 2017 to Jun 2019. Out of 328 patients, brain oedema due to spontaneous ICHs was 219 (66.77%) and traumatic ICHs were 109(33.33%). Diagnosis was based upon history, clinical examination and non-contrast Computed Tomography (CT) scan of brain. Results: Total 328 admitted patients in CMH Dhaka from Jan 2017-Jun 2019 were included in our study who full-fill the criteria. Males were 231 (70.43%); females were 97(29.57%) and were aged between 1 to 95 year. Intracranial haemorrhage rate among age group less than 55 years old being 76 (34.70%) and 55 years or above 143 (65.30%) of total 219 patients. Traumatic ICHs were 109 and 1 to 44 years age is most vulnerable, 69(63.30%) and 45 years and above 40 (36.70%) patients. Corticosteroid was used after vasogenic brain oedema formation following cytotoxic oedema which was diagnosed mainly radiologically. Cytotoxic oedema induced by 24 hours and vasogenic oedema in two to four days of brain insult. Vasogenic oedema developed in 24 -48 hours, 65 (19.82%) patients and 117 (35.67 %) by 48-72 hours and above 72 hours rest 146 (44.51%) patients after brain insult. After vasogenic oedema formation, out of 164 patients that is 50% patients were treated with corticosteroid and GOS was assessed- GOS 4,5 -103(62.80%), GOS 3-34 (20.73%), GOS 2- 23(14.02%) and GOS 1-4(2.44%) whereas without corticosteroid treatment of rest vasogenic oedema 164 (50%) , GOS was- GOS 4,5 -85(51.83%), GOS 3-43 (26.22%), GOS 2- 27(16.46%) and GOS 1-9(5.49%) at 30 days of incidence. There is more than two times mortality without corticosteroid therapy than with steroid therapy. Conclusion: Cytotoxic brain oedema is contraindicated for steroid but we observed that corticosteroid gives better GOS in vasogenic oedema which develops after cytotoxic brain oedema. Outcome in cytotoxic oedema followed by vasogenic oedema is beneficial for corticosteroid. Bang. J Neurosurgery 2020; 10(1): 45-51

Histopathological Pattern of Spinal Tumor: Experience of 57 Cases in Bangladesh

Background: Spinal cord tumors are presented with different histopathological pattern. Objective: The purpose of the present study was to see the different histopathological pattern of spinal tumor. Methodology: This descriptive cross sectional study was conducted in the Department of Neurosurgery at National Institute of Neurosciences & Hospital, Dhaka, Bangladesh from January 2016 to December 2019 for a period of 04 (Four) years. Patients presented with spinal tumor were selected as study population. After surgical removal the spinal tumor, tissue was sent for histopathological examination to the Department of Neuropathology of the same institute. Result: A total number of 57 spinal tumor cases were recruited for this study. The male and female ratio was 1.34:1. Out of 57 spinal tumor mostly were located in the intradural extramedullary (IDEM) which was 39(68.4%) cases. Extradural and intramedullary were found in 7(12.3%) cases in each. Most of the spinal tumor were Schwannoma which was 28(49.1%) cases. Neurofibroma and meningioma were found in 6(10.5%) cases in each. Lipoma was found in 3(5.3%) cases. Ependymoma was found in 4(7.0%) cases. Conclusion: In conclusion Schwannoma is the most common variant of spinal tumor detected among the study population. Bang. J Neurosurgery 2020; 10(1): 27-32

Giant Solitary Plasmacytoma of Skull: A Case Report

Plasmacytoma is a tumor arising from plasma cell, which mainly grows within soft tissue or within axial skeleton, when it is present as a discreet solitary mass it is called as solitary plasmacytoma & it is rare, we report a 46 years male, presented to us with the complaints of painless swelling in the left frontoparietal region which is about 8.6x6.5cm in diameter, Magnetic resonance imaging revealed an extra axial mass in fronto parietal region with overlying bone destruction mimicking meningioma with bony erosion, we did frontoparietal craniectomy and complete resection of tumor with bony margin subsequently cranioplasty was also done, histopathology of which revealed plasmacytoma,after that we did urinary bence jones protein which was negative. Bang. J Neurosurgery 2020; 10(1): 106-110

Asymptomatic Extradural Hematoma-Our Observation In DMCH

Background: Surgical management of extradural hematoma is evacuation of extradural hematoma until otherwise. But, a number of authors have suggested that small epidural hematoma may be managed conservatively with normal outcome in selected cases. The goal of this study was to define the clinical and radiological parameters that may help in the management of the patient with small epidural hematoma where the hematoma was asymptomatic. Objective: This study was conducted to find out the factors influencing the decision making in the management of asymptomatic extradural hematoma though they have no evidence of raised intracranial pressure or any focal neurological deficit. Methods: Three hundred patients were evaluated clinically and by CT scan of head to see of hematoma, location of hematoma, midline shifting and overlying skull fractures etc. Results: All 300 patients were diagnosed within 72 hours of trauma and were tired to be managed expectantly but was not possible sometimes. All these patients were analyzed on the basis of tome since trauma, GCS score, overlying skull fracture traversing any artery, vein or any venous sinuses. Among 300 patients 225 (75%) patients underwent CT scan of head within 24 hours of trauma and 185 (61.67 %) patients had overlying skull fracture. 51 (17%) deteriorated later on and 31 (10.33%) patients among them required surgical evacuation of hematoma. Conclusion: It can be concluded that patients with small epidural hematoma with a fracture overlying major vessels or major sinuses, diagnosed within 24 hours of trauma are at risk of subsequent deterioration and may require surgical evacuation. Bang. J Neurosurgery 2020; 10(1): 20-26

Microsurgical Excision of Olfactory Groove Meningiomas, Comparative Studies of Different Surgical Approaches

Introduction: To review the surgical approaches, techniques, outcomes and recurrence rates in a series of 11 olfactory groove meningioma (OGM) patients operated from January 2010 to April 2019. Methods: Eleven patients underwent craniotomy and micro-neurosurgical removal of olfactory groove meningioma. Tumor diameter varied from 5 to 8.5 cm among 11 cases, 2 cases underwent Transglabellar/ Subcranial approach, 3 cases by bifrontal approach, 1 case unifrontal approach, 2 extended endonasal and 3 cases fronto-lateral approach. Result: Total removal was possible in all cases except 2 cases. Histopathology revealed typical meningioma (WHO grade 1). There was 1 operative mortality and no permanent focal neurological deficit except anosmia. 3 patients developed CSF leak and two cases meningitis which were resolved by lumber drain and antibiotic therapy. Conclusion: Extended endonasal approach or transglabellar/ subcranial approach were sufficient for gross total removal of OGM which is associated with bony hyperostosis, paranasal extension and optic canal. Bang. J Neurosurgery 2020; 10(1): 9-19

Correlation between the Size of Tumour with Early Postoperative Serum Sodium Imbalance in Sellar and Suprasellar Space Occupying Lesion after Transsphenoidal surgery

Background: Seller and suprasellar space occupying lesions are frequently encountered intracranial lesions now-a-days. Surgery through transsphenoidal route is the most preferable approach which is frequently performed for excision of these space occupying lesions. The lesions are located in a very critical area because they are surrounded by the hypothalamus, pituitary gland and cavernous sinus which are responsible to maintain various hormonal functions as well as regulation of plasma osmolality and plasma electrolytes. So, during and after operation various types of osmolality and electrolytes related complications are often encountered. Among them serum sodium imbalance is the most frequent one. Objective: Tumour size is one of the very important predisposing factors which influence the serum sodium level after surgery. For investigating the correlation between the size of sellar and suprasellar space occupying lesions with the incidence of postoperative sodium imbalance after transsphenoidal surgery of the patient having these lesions. Material and method: Thirty patients with sellar and suprasellar space occupying lesions meeting the inclusion criteria were enrolled. The largest diameter of the tumour was measured in the coronal or sagittal planes from pre-operative MRI’s. They underwent transsphenoidal surgery and were observed for first 7 postoperative days and serum electrolytes was measured every day. Patients in this study were considered to have serum sodium imbalance if the narrow range of 135-145 mmol/L was not maintained. Then according to the tumour size they were divided in to two groups. Then the two groups were compared and the frequency of development of post-operative sodium imbalance, their time of onset and types of imbalances were observed. Result: 60% of the patients in our study developed post operative serum sodium imbalance after transsphenoidal surgery. Among them 40% of the patients developed hypernatraemia, 13.3% of the patient developed hyponatraemia and only 6.7% patient developed combined imbalance. Hypernatraemia is more common than hyponatraemia after transsphenoidal surgery. Peak incidence of hyponatraemia occurred on 3rd post-operative day and hypernatraemia occurred at 1st postoperative day. In the large size tumour group (>30mm) 46.66% had serum sodium imbalance and imbalance was observed in 13.33% of the small size group (d”30mm) and there is significant difference of sodium imbalance between large and small size group and p-value was 0.001. r- value 0.776 indicates that the size of the tumour strongly correlates with postoperative sodium imbalance and there is significant association between size of the tumour with sodium imbalance. The study found no significant association between age, sex or types of the lesions with postoperative sodium imbalance (p=0.43). Conclusion: Post operative serum sodium imbalance after transsphenoidal surgery is a burning issue for the neurosurgeon now a day. Early prediction of these types of notorious complication is helpful for preoperative and post operative management of the patient. The size of the lesion is one of the most significant markers. As well as a strong association between size of the tumour with post operative sodium imbalance was found. This will help us in perioperative management of the patients, and reduces complication related mortality and morbidity after the transsphenoidal surgery. Bang. J Neurosurgery 2020; 10(1): 82-91

Incidence of Motor Cycle Accidents in Female Traveller in the Neurosurgery Ward of Rangpur Medical College Hospital

Background: Motor bike is a popular two wheeler vehicle in Bangladesh especially among young generation, newly married couple and service holders. It is also popular vehicle among female NGO workers. Female like to travel on motor bike along with life partner or with guardian hanging their both legs on one side of seat increasing the tendency to fall down from motor cycle due to imbalance body weight during turning the road or crossing the uneven road or sudden increasing the speed of the motor bike or crossing on a speed breaker. Aims: Encourage female to travel on motor bike hanging their legs on both sides of the seat to maintain the body weight balance for reducing the mortality and morbidity of RTA. Methods: All the female patients admitted in neurosurgery ward having motor cycle accident from January/2019- December/2019 were included in this study. Results: There is a strong association between fall from motor cycle (RTA) and hanging two legs on one side in female motor cycle traveler. Conclusions: female should travel on motor cycle hanging their legs on both side of seat to avoid avoidable head injury due to RTA. Bang. J Neurosurgery 2020; 10(1): 33-38