The Surgical Results in Pure Endoscopic Endonasal Trans-sphenoidal Surgeries in 403 Pituitary Adenomas: An 8-Years of Experience from a Single Neurosurgical Unit

Objective: To review and report the results in pure endoscopic endonasal trans-sphenoidal surgery done at our unit for pituitary adenomas (PAs) in last 8 years. Material and Methods: We reviewed 403 consecutive patients who underwent pure endoscopic endonasal trans-sphenoidal surgery for newly diagnosed pituitary adenomas between August 2012 and July 2020 at our neurosurgical unit. Endocrinological, demographic features and outcomes, their complications, and duration of stay in hospital were assessed in these patients who were operated in our neurosurgical Unit. The Mean Follow-up on average was 3.5 months. Results: 403 consecutive cases were reviewed. Majority of cases were in the 4th decade of life at presentation. 227 (56%) were non-functioning pituitary tumors and 176 (44%) were hormone secreting pituitary adenomas. Thirty-one (7.7%) complications were observed in 28 post-operative patients. The most frequently observed complication was diabetes insipidus (temporary in 19 (5%) and permanent in 3 (0.7%) cases), cerebrospinal fluids leaks (5 cases) (5.7%), Syndrome of inappropriate antidiuretic hormone (1 case) (0.2%), internal carotid injury (1 case) (0.2%), Empty Sella syndrome (1) (0.2%) and post-operative cardiac complication (1 case) (0.2%). The Follow-up on average was 3.5 months. Conclusions: The pure endoscopic endonasal trans-sphenoidal surgery of pituitary adenomas provides acceptable and reasonable results representing a safe alternative procedure to the traditional Trans-sphenoidal microscopic approach.

Hemorrhagic Stroke May Be the Sequelae of Brain Tumors

Objective: Hemorrhagic stroke is a common neurosurgical emergency caused by multiple pathological conditions. Brain tumors can also present with acute neurodeficits secondary to hemorrhagic stroke. This study as case series was conducted to report the clinical presentation, radiological findings, causes and management of brain tumors presenting as hemorrhagic stroke. Materials and Methods: Clinical assessment and radiological investigations were done, including CT brain and MRI brain with contrast. Surgery was done with evacuation of the hematoma and excision of tumor, and the tissue was sent for histopathology. Post operatively patients were shifted to the intensive care unit for monitoring and ventilator support if needed. Adjuvant treatment was guided according to histopathology report. Results: Total number of patients who were diagnosed to have a bleed in brain tumor were thirteen (n = 13). There were 6 (46%) males and 7 (54%) females. Mean age was 55 years. Among 13 patients, 4 (31%) patients had metastatic brain tumors and 9 (69%) patients had primary brain tumors. Diagnosis was done on CT brain, MRI brain and confirmed on histopathology of tissue obtained during surgery. Out of 13 patients, 5 (38%) patients were asymptomatic prior to hemorrhage and 8 (62%) patients had neurodeficits before and recent episodes of bleeding, which caused deterioration of neurological state. Conclusion: Malignant primary and metastatic brain tumors can present as acute focal deficits due to brain hemorrhage. Diagnosis is based on clinical presentation, radiological features and histopathology.

Outcome in Normal Pressure Hydrocephalus after Ventriculoperitoneal Shunt in Tertiary Care Hospital

Objective: To determine the outcome of the ventriculoperitoneal shunt in normal pressure hydrocephalus. Material and Methods: This study was conducted at Jinnah Postgraduate Medical Centre, a tertiary care hospital in Karachi. Patients with idiopathic normal pressure hydrocephalus (NPH) were included. Gender distribution, presentation of symptoms and post-operative outcome based on the Stein Langfitt Scale were assessed. CSF was sent for microbiological and biochemical analyses. All patients were evaluated preoperatively and compared postoperatively during 6 months duration for improvement and any associated complication. Results: In this study, we had 47 patients, 38 were male and 9 were female. 22 patients presented with dementia, 18 with urinary incontinence, 17 with gait disturbance 17, while 21 had headache based on Stein and Langfitt Scale. The 78.8% patients had an excellent outcome, 17% had a good outcome and 4.2% had poor results. Conclusion: Ventriculoperitoneal (VP) shunt had promising results selected on history and examination of normal pressure hydrocephalus and improved radiological in Evan’s ratio CT brain scan. Keywords: Normal Pressure Hydrocephalus (NPH), VP Shunt, Stein and Langfitt Scale.

Experience with Ventriculoatrial Shunt

Cerebrospinal fluid (CSF) diversion through shunting, either internal or external, is the standard of care for hydrocephalic patients. Although Ventriculoperitoneal (VP) shunt is always the first choice, right atrium for Ventriculoatrial (VA) shunt is considered a suitable and convenient option for drainage of excess CSF in patients with history of abdominal surgeries, peritoneal infection or shunt obstruction.1 Here we are reporting our experience with a patient who underwent VA shunt insertion because of a previous malfunctioning VP shunt. A thorough review of the literature revealed that, although reported worldwide, there is an apparent deficiency of similar reports from Arabian Gulf region. Through this case report, we aim to shed light on this internal CSF diversion method, which could be considered in centers lacking advanced care facilities for procedures like Endoscopic 3rd Ventriculostomy (ETV).

Outcome of Deep Brain Stimulation (DBS) for the Treatment of Parkinson’s Disease in Terms of Improvement in MDS-UPDRS Scale Over 5 Years

Background & Objective: Parkinson’s disease (PD) is the second most common Neurodegenerative disorder after Alzheimer’s disease. There are several surgical procedures for advanced PD, but amongst all deep brain stimulation has proven to be safest and effective. The objective of this study was to see the outcome of DBS for the treatment of PD in terms of improvement in MDS UPDRS over 5 years. Material and Methods: 44 patients were included in study from Oct 2014 to Sep 2019. History, examination was carried out, and preoperative MDS-UPDRS (Movement Disorder Society Unified Parkinson’s Disease Rating Scale) was recorded. Postoperative improvement in MDS-UPDRS score was assessed at first Programming, 2nd week, and 6th week and at 3rd month. Results: At baseline the mean, the MDS – UPDRS (Part-I) score was 14.20 ± 0.61 and at the end of 3rd month, the mean score was 11.18 ± 0.47 respectively. At baseline the mean, the MDS – UPDRS (part-II) score was 18.99 ± 0.70 and at the end of 3rd month, the mean score was 13.01 ± 0.57, respectively. At baseline the mean, the MDS – UPDRS (part-III) score was 45.19 ± 0.90 and at the end of 3rd month, the mean score was 25.15 ± 1.20 respectively. At baseline the mean, the MDS – UPDRS (part-IV) score was 10.18 ± 0.87 and at the end of 3rd month, the mean score was 3.85 ± 1.03, respectively. Conclusion: The Deep Brain Stimulation (DBS) is safe and effective in the management of PD.

Glue That Pain: A Case Report and Review of Literature

Tarlov cysts are cystic lesions of the nerve root sheath in the lower spine. With a reported incidence ranging from 1 to 5%, these lesions are fairly rare, benign and often asymptomatic. When they cause neural compression they may become symptomatic with sensory, motor, bowel/bladder and sexual dysfunction. The treatment of symptomatic Tarlov cysts is a controversial issue, ranging from conservative management and local steroid injections to a bewildering assortment of surgical options including CSF diversion procedures and advance microsurgical approaches with various ways of cyst manipulation. All these surgical modalities carry a high risk of serious complications, recurrence with need of a redo operation and a very variable rate of symptomatic relief ranging from 38 – 100 % in different series. Developing from the CT guided needle aspiration of the cyst which suffered disappointment in the form of re accumulation and heralded by earlier reports of aseptic meningitis, CT guided aspiration and subsequent filling of the cyst with fibrin glue has now emerged as a safe, highly effective and first line of treatment for symptomatic Tarlov cyst.

Pattern of Skull Fractures and Its Outcome in Pediatric Head Injury Patients

Objective: Skull fractures are common in pediatric age group. The surgical management of paediatric patients with a skull fracture differs among institutions and surgeons. Our object of this study was to assess the pattern of skull fractures and outcome in paediatric population. Material and Methods: This study was conducted in the department of neurosurgery of a tertiary care hospital from June 2018 to April 2020. We included 152 children between ages 5 to 11 years who were brought with the head trauma and diagnosed to have skull fracture on computerized tomography (CT) Scan brain. Results: The mean age of patients was 6.91 + 1.84 years. There were 59.8% males and 40.1% females. The most common type of fracture at presentation was depressed fracture in 42% patients, followed by linear (35%) and compound fractures (23%). Parietal fractures were the commonest (63.1%) in our study. Associated intracranial hematomas were seen in 37.5% patients, epidural hematoma being the most common. Surgically treated patients were 36%. Good recovery was seen in 73% patients while mortality was 10.5%. Conclusion: Isolated skull fractures are overall benign conditions. Linear parietal skull fractures have good outcome amongst all fracture types.

The relationship between the grading of lumbar spinal stenosis and pain improvement after caudal epidural steroid injection.

Objective: This study aimed to determine the relation of severity of lumbar spinal stenosis and pain improvement after caudal epidural injection. Material and Methods: 70 patients of neurogenic claudication were included from July 2019 to June 2020. MRI lumbosacral spine was done of all patients to categorize the degree of spinal stenosis on T2-W axial. All patients were given caudal epidural steroid injection as a day case procedure. Follow-up was done at 3 & 8 weeks and pain improvement was assessed by using Ronald satisfaction score. Results: Mean age was 37.9 ± 7.8 years. 48.6% patients were male and 51.6% were female. The improvement was observed in 28 patients (40%) at 3 weeks and in 46 patients (65.7%) at 8 weeks. There was no statistically significant relationship between lumbar spinal stenosis and pain improvements at 3 weeks (p value 0.30) and 8 weeks (p value 0.32). Conclusion: The grade of lumbar spinal stenosis has no significant effect on pain improvement after caudal epidural steroid injection. Keywords: LSS (Lumbar spinal stenosis), caudal epidural steroid injection (ESI), neurogenic claudication, MRI (Magnetic resonance imaging), T2W (T2 weighted) images.

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.

Effects of Magnesium Sulfate Therapy on GCS Scores in Patients with Severe Traumatic Brain Injury

Objective: Traumatic brain injury (TBI) is the number one cause of death under 44 years of age; in spite of this fact, there is no standard available pharmacological agent for the treatment of brain injury. We evaluated the effectiveness of magnesium sulfate treatment for the management and outcome of TBI. Material and Methods: The prospective cases (n = 60) of TBI were included with non-probability consecutive sampling. They received standard protocol treatment for TBI and magnesium sulfate as an add on therapy. GCS was noted on two occasions, at the time of admission and on the 3rd day. T-test was used to compare the results and for identification of significance/insignificance results. Results: Mean age of the patients was 37.12 ± 13.25 years. Majority were male (68.3%), while females were 31.7%. Mean duration of an elapsed post traumatic brain injury was 5.06 ± 2.32 hours. Mean GCS before magnesium sulfate treatment (on admission) was 5.46 ± 1.521; mean Glasgow coma (GCS) after magnesium sulfate treatment (on 3rd day) was 8.03 ± 2.56. There existed a significant difference between the GCS scores at the time of admission and on 3rd day (p value < 0.0001). Mean GCS was 7.69 ± 2.55 in age < 30 years and it was 8.29 ± 2.57 in age > 30 years, but this difference was not statistically significant. Conclusion: A significant improvement was found in the GCS after magnesium sulfate therapy in patients with TBI.