COVID-19 pandemic and its influence on mental health of healthcare professionals in Nepal

Given the unprecedented global public health crisis due to the covid-19 pandemic, it is important to recognize the psychological impact on health care professionals. Previous experiences from the smaller scale epidemiology and new literature on COVID-19 have shown that increased pressure on healthcare professionals is associated with rise in the psychological incidence rates. We have described the psychological burden of the covid-19 pandemic on health care workers in Nepal and reviewed the literature on the impact of previous epidemics on front-line health care workers. In addition, we discussed potential triggers and measures to minimize the front-line psychological pressure to deal with this biological threat.

Successful Mechanical Thrombectomy of Middle Cerebral Artery Occlusion 14 Hours after Stroke Onset

A 45-year-old patient with no significant past medical history presented to out-patient department with aphasia and right hand weakness with a National Institutes of Health Stroke Scale (NIHSS) of 10 and occlusion of the left middle cerebral artery (MCA) in the M1 segment. Last known normal time was 14hrs (wake up stroke). Immediate endovascular thrombectomy was performed 14 hours after symptom onset with complete recanalization and complete clinical recovery. Although mechanical thrombectomy is generally considered an effective alternative strategy up to 8 hours after stroke onset, selected patients with a large diffusion/perfusion mismatch and small infarct cores may benefit from an expanded therapeutic window.

Changing Paradigm for Brain AVM Treatment

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Quasi Moyamoya Disease: Case report and literature review

Quasi moyamoya disease is the unilateral form of typical moyamoya disease which is associated with acute or chronic stages of inflammatory diseases. Here, I present 21-year-old boy presented with sudden onset of weakness of right sided limbs following physical workout, had acute ischemic infarction of left internal capsule in diffusion restriction MR image and unilateral steno- occlusive changes of terminal portion of left internal carotid artery was noted in digital subtraction angiography.

Neurobehavioral Changes: An under looked aspect of Head Injury

Background: Different types of behavioral changes are seen in head injury patients, and these changes are directly or indirectly related to daily activities. Major alterations of personality after head injury are generally seen in the patients with severe head injury. However, disturbing post-concussional symptoms like headache, dizziness and memory problems generally persists for few months even in the less severely injured ones. Materials and methods: Objective: To analyze the neurobehavioral changes in adult head injured patients. Study design: Prospective analytical study. Sampling technique: Non - probability consecutive sampling. Site of study: National Institute of Neurological and Allied Sciences, Bansbari, Nepal. Inclusion Criteria: All head injured patients above the age of 16 years. Exclusion Criteria: Extended Glasgow Outcome Scale of less than 3 at 6 months follow up. Data Collection and Analysis: All patients above the age of 16 years with head injury who got admitted were enrolled in the study. Parameters like age, gender, mode of injury, GCS at presentation were recorded. Extended Glasgow Outcome Scale along with Neurobehavioral rating was evaluated at 6 months. Then neurobehavioral rating scale was obtained by direct interview. Data analysis was done using SPSS v.20. Results: Total number patients were 76 among which 71% were below 40 years of age and majorities (87%) were males. Neurobehavioral categories like abnormal intentional behavior, lowered emotional state, heightened emotional state, arousal state and language had significant association with GCS at presentation and EGOS at 6 months. Similarly, age had significant association with language, where there was absent to mild language difficulty in patients below 40 years of age. Likewise, language difficulty, lower emotional state and abnormal intentional behavior were significantly associated with gender, as it was mild to severe in 30% of the female population who had sustained head injury. Conclusion: Several neurobehavioral characters seem to be present in the various categories of the head injured patients in different ratios. Language problems seems to be less in the younger patients below the age of 40 years; although, few neurobehavioral parameters seems to affects the females more common compared to male counterparts. Also, family disruption and its extent of severity was significantly related to the severity of head injury.

Role of early surgical intervention in outcome and prognosis of spontaneous cerebellar hemorrhage with intraventricular extension

Spontaneous cerebellar hematomas represent 5 to 13% of all cases of spontaneous intracranial hemorrhage. The main controversy involves deciding which cases require surgical evacuation of the hematoma versus other options, such as ventricular drainage only or conservative treatment. Furthermore, because the clinical course is variable in some cases, timing of such treatment should be carefully considered. The duration from the onset of hemorrhage also plays an important role in prognosis and recovery of the patient. Both the clinical presentation and subsequent course vary among cases. Unpredictable rapid deterioration in consciousness levels has been recognized. The majority of patients with such decline in consciousness experience the deterioration primarily within 72 hrs after onset⁠. Acute presentation was observed to be correlated with poor outcomes. In our report, the first case presented with sudden onset of headache in the right frontal region of head with vertigo. He came to hospital within 6 hours of onset. However, the second case had an onset of symptoms around 72 hours before the presentation.

Demographics, Clinical profile, Causes and Outcome of Intracerebral Hemorrhage in Neurosurgical Unit in Manipal Teaching Hospital of Western Nepal

Background: This research article aims to evaluate the demographic variables, clinical profile, causes and outcome determinants of spontaneous intracerebral hematoma (SICH) in a population of Western Nepal. The study represents the cases of SICH reported from Manipal Teaching Hospital, a tertiary center at Gandaki province of Western Nepal. Materials and methods: Retrospective data collection and analysis were done with consecutive cases of SICH admitted to our center between January 2018 and March 2019. The variables analyzed include age, gender, chronic conditions like hypertension, diabetes mellitus, history of tobacco abuse, alcohol abuse, Glasgow coma score (GCS) on admission, radiological(CT scan) findings, treatment modality, an outcome at 6 months period, etc. Modified Rankin score (mRS) was used to assess the outcome at discharge and after six months. Results: Our study group of 237 patients included 171 males and 66 females and the mean age of presentation was 64.02 years. The study group included 121 patients (51.1%) who were previously diagnosed with systemic arterial hypertension and 15 patients diagnosed with diabetes mellitus. The most frequent locations of hematoma were basal ganglia (n=127), lobar (n=94), intraventricular hemorrhage (n=69), cerebellar (n=15) and brainstem (n=11). The mean volume of the blood clot on admission was 25.97 ml. surgical evacuation of hematoma and decompression through craniotomy was done in 52 (21.9%) patients. Independent predictors of unfavorable outcomes includes the variables like headache (p=0.007), aphasia (p=0.017), mean GCS score (p=0.00) and motor GCS score (p=0.00); CT finding of intraventricular extension of hemorrhage (p=0.00), midline shift (p=0.00), intracerebral blood volume (p=0.00); and surgery (p=0.007). Conclusion: ICH predominantly affects a younger population in Nepal in comparison to the Western world. The variables include clinical features like headache, aphasia, pupillary size and reaction, mean GCS score and motor GCS score; CT finding of intraventricular extension of hemorrhage, midline shift, intracerebral blood volume; and surgery were the predictors of an unfavorable outcome. On binary logistic regression, the ICH score was the most consistent predictor of unfavorable outcomes in terms of MRS (OR 2.236, p=0.002).

Non-Hodgkins Lymphoma Presenting as a Skull Metastases: Case Report

The incidence of cerebral metastases has increased over the last few decades mainly due to the successful treatment of extra neural cancers and the prolonged survival of patients. The common causes of metastases are lung, kidney, breast and thyroid cancers. We present an interesting case of cerebral metastases that was managed as cerebral abscess, then as lung metastases before finally arriving to the correct diagnosis of Non-Hodgkin’s Lymphoma.

Acute Sub temporal and Infratemporal Dumbbell Abscess Secondary to Tooth Extraction: Case Report

To present a case of acute temporal and infratemporal dumbbell abscess following tooth extraction and discuss the possible anatomic pathways of spread of odontogenic infections. This is a case of right maxillary tooth extraction following which he developed local infection that spread to the temporal and sub temporal space. The history and examination revealed the infection spreading to the buccal and sub temporal space with trismus and feeding problems. Intraoral and external drainage along with antibiotics led to the resolution of the abscess. Of the many complications of tooth extraction infection spreading along the temporalis with formation of a dumbbell abscess can lead to severe discomfort and septicemia if not detected and treated early. A case with successful management and result are discussed.

Effect of Concomitant Extra cranial Injury in outcome of moderate and severe head injury patients admitted to a tertiary care hospital in western Nepal

Background: Polytrauma is a term used to describe the patients those are severely injured associated with other injuries (i.e. two or more severe injuries in at least two areas of the body), less often with a multiple injury (i.e. two or more severe injuries in one body area). More than 40% of the patient of Traumatic Brain Injury (TBI) dies due to extra cranial causes. We hypothesized that extra cranial injuries with polytrauma may alter TBI outcomes and perform the study. Materials and methods: An analytical study was done with the patient of moderate to severe head injury admitted to neurosurgery Intensive Care Unit (ICU) of Manipal Teaching Hospital in between January to December 2019. The objective of the study was to assess the impact of concomitant extra cranial injury (Polytrauma) in the outcome of Moderate to severe head injury. Results: In our study it is seen that, those individuals who have presented delayed in emergency department from the time of incidence under the influence of alcohol, likewise with mean Glasgow Coma Scale (GCS) below 8.16+/-3.22 and abnormal pupils, high injury severity score (ISS), and with polytrauma have poorer outcomes. Conclusion: Concomitant extra cranial injuries, injury severity score(ISS),injuries associated under the influence of alcohol, delayed presentation in emergency after incident, GCS below 9 during presentation in ER and abnormal pupils during examinations are the strong predicting factors for the poor outcome of patient with traumatic brain injury.