Impact of gender and age on inner diameter of arteries forming circle of Willis assessed by multidetector CT

Introduction: The circle of Willis (CoW), which is located at the base of the brain is the most important anastomosis between the internal carotid and vertebral system. It is the main distributor of blood to the brain. Methods: CT head and CT angiography were performed using standard scan parameters. Only the tests with normal radiological reports and appropriate technical standards were included in the study. Component of circle of Willis: Anterior cerebral artery (ACA), Middle cerebral artery (MCA), Anterior communicating artery (Acom), Posterior Communicating artery (PCom), Basilar artery (BA) and Posterior cerebral artery (PCA) were identified and their internal diameter were measured. Results: Basilar artery was the artery with largest internal diameter with mean diameter of 2.5 ±0.52 mm. Men had significantly larger arterial sizes than women in all of the intracranial arteries examined except right PCom, Left PCom and right MCA. Right ACA had significantly larger internal diameter in <40 years’ age group. BA, left PCA, Bilateral PCom and MCA showed larger diameter in age group ≥40 years. Conclusion: Men had significantly larger arterial sizes than women in all of the intracranial arteries examined except right PCom, Left PCom and right MCA.

Factors Predicting outcome of patients with polytrauma in tertiary center of western Nepal

Introduction: Trauma is a public health issue associated with substantial socioeconomic impacts and major adverse clinical outcomes. No single study has previously investigated the predictors of mortality in a general trauma population. In this study, we assessed different clinico-biochemical parameters to investigate the associations between those parameters and their effects in outcome of a polytrauma patient. Methods: An analytical study was done in between January 2020 to December 2020 in patients with polytrauma admitted to intensive care unit Department of Surgery in Manipal Teaching Hospital to assess the effect of various socio-demographic and clinic-radiologic variables in outcome (Glasgow outcome scale) of polytrauma patients. All the categorical data were tested using chi square test or Fischer Exact test and continuous variables were tested using student’s “t” test. P value <0.05 was determined significant. Those independent variables significant on univariate analysis were then subjected to binary logistic regression and the data was presented as level of significance, odds ratio and 95% confidence interval. Analysis was done using SPSS 23.0. Results: Out of 67 patients, 34 had favorable GOS and 33 had unfavorable GOS. Injury Severity Score (ISS) (P<0.01), abnormal pupils (P<0.01), RBS (0.04), low GCS during presentation (<0.01), higher CT Marshal Grade (0.01) had strong associations with unfavorable outcome in polytraumatic patient. ISS was the only significant parameter when all the other significant variables were kept constant in binary logistic regression model (OR=1.18, 95% CI=1.08-1.28). Conclusion: Injury Severity Score, abnormal pupils during presentation, high level of blood sugar after polytrauma, low GCS during presentation, higher CT Marshal Grade are strong predictors in outcomes of polytraumatic patient.

Role of CT scan in modern Neurosurgery

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Factors predicting pneumonia in patients admitted with spontaneous supratentorial intracerebral hemorrhage in western region of Nepal

Introduction: Despite the well-documented association of stroke-associated complications and infections with increased mortality, morbidity and worse long-term outcome, there are only limited data available on independent predictors of pneumonia in patients with acute intracerebral hemorrhage. In this study, our objective was to evaluate risk factors and comorbid conditions associated with the diagnosis of hospital acquired pneumonia in the patients admitted with spontaneous intracerebral hemorrhage and to determine the independent predictors of pneumonia in these patients. Methods: A retrospective analysis was done in patients admitted in Intensive Care Unit of Nepalgunj Medical College with spontaneous intracerebral hemorrhage. Various clinic-demographic parameters were tested for association with pneumonia or no pneumonia group using chi square or student’s “t” test. Results: A total of 117 patients, 86 men (73.5%) and 31 women (26.5%) with spontaneous intracerebral hemorrhage were included in the study. There were 36 (30.77%) patients with pneumonia. The association Diabetes mellitus (p<0.01), COPD (p<0.01), smoking (p<0.01), mean GCS (p<0.01), ICH volume (p=0.01), ICH score (p<0.01), operated status (p<0.01), Ganglionic (<0.01), Brain stem (p=0.03) and Ventricular (p=0.01) location of hematoma was statistically significant with pneumonia. Outcome in terms of MRS at discharge was also poorer for patients with pneumonia (p=0.01). Conclusion: Diabetes mellitus, COPD, mean GCS, ICH volume, ICH score, operated status, higher MRS score were associated with increased risk of pneumonia in ICH. Similarly, ganglionic hematoma, brainstem hematoma and those having intraventricular hemorrhages are also associated with increased risk of pneumonia. Outcome in patients in terms of MRS were also poorer in those who had pneumonia.

Study of Carotid doppler in Patients with ischemic stroke

Introduction: Stroke is one of the major causes of increased morbidity and death. Large-vessel atherosclerosis of intracranial and extra cranial carotid vessels is an important cause of ischemic stroke. This research was undertaken to study the carotid Doppler findings in patients with acute ischemic stroke. Methods: A hospital-based prospective cross-sectional study was conducted from January 2020 till December 2020 in the department of Radio diagnosis and Imaging at Manipal Teaching Hospital, Pokhara, Nepal. Neuro-imaging and carotid Doppler findings in patients with ischemic stroke were studied. Data analysis was done using SPSS 20. Results: The mean age of subjects with ischemic stroke was 64 ± 13.4 years with the majority of cases in the age group of 51-70 years of age with male predominance (M: F= 3: 2). Lacunar infarcts (34.2%) were the most common findings followed by MCA infarct (30%) and ACA infarct (10.8%). Carotid plaques were seen in 43.3% patients. Bilateral ICA atheromatous plaque was seen in 48.1% of patients. Carotid bulb was the common site for plaque formation. Type III plaque was the commonest type. Significant ICA stenosis > 50 % was observed in 24.2% patients. Age >50 years, male sex, smoking, hypertension, diabetes, and hyperlipidemia were important risk factors. Conclusion: Carotid artery Doppler demonstrated atherosclerotic plaques and significant stenosis in patients with ischemic stroke. Increasing age >50 years, male sex, smoking, hypertension, diabetes, and hyperlipidemia were associated with an increased rate of atherosclerosis, carotid stenosis and ischemic stroke.

Sphenoid sinus pneumatization in a sample of Nepalese population: A multidetector computed tomography study.

Introduction: The purpose of study was to assess the prevalence of different types of pneumatization of sphenoid sinus in the Nepalese population as detected in CT scan of paranasal sinus. Materials and Methods: This study included patients attending radiology department for CT scan of paranasal sinus. The CT images of paranasal sinus were assessed for the type of pneumatization of the sphenoid sinus and type of clival, lateral recess and lesser wing extensions. Results: Most common type of pneumatization found in our study was complete sellar type (61.7%) and partial sellar type was second common type (27.4%). Pre-sellar type of pneumatization was seen in 10.9%. There were no patients with conchal type of pneumatization in our study. The clival extension of pneumatization was seen in 64%, lateral extension was found in 35.4%. and lesser wing type of pneumatization was found in 9.7%. Conclusion: Pre-surgical assessment of types and extension of sphenoid sinus pneumatization helps surgeons in surgical planning and to reduce complications during surgery. The variation in prevalence of sphenoid sinus pneumatization was found between our study population and other different population. This confirms that ethnicity influences types and extension of sphenoid sinus pneumatization.

Role of Natalizumab in Relapsing-Remitting Multiple Sclerosis: A review

Introduction: Multiple sclerosis is a non-traumatic neurological disease caused by an immune-mediated reaction leading to a chronic inflammatory demyelinating disorder of the central nervous system. The treatments for multiple sclerosis are mainly divided into three categories: treatment of exacerbation, slowing disease progression with disease-modifying therapies, and symptomatic therapies. Natalizumab is a monoclonal antibody that works by preventing the adhesion of lymphocytes into the endothelium of the blood-brain barrier, reducing lymphocyte infiltration into the central nervous system. This review aims to study the efficacy and safety of natalizumab in relapsing-remitting multiple sclerosis. Methods: The review was performed using databases like PubMed, Cochrane library, Google scholar from which 48 relevant articles were selected based on the various inclusion criteria. The following keywords were used: “Natalizumab”, “Multiple sclerosis”, “side effects”, “Relapsing-remitting multiple sclerosis”, “progressive multifocal leukoencephalopathy” in different combinations. Results: The literature review suggests that natalizumab reduces the rate of sustained progression of the disease and disability, and was associated with a lower relapse rate in patients with relapsing-remitting multiple sclerosis. However, Progressive multifocal leukoencephalopathy is one of the serious side effects of natalizumab. Conclusion: The literature review suggests that Natalizumab has favorable outcomes in patients with relapsing-remitting multiple sclerosis. Since progressive multifocal leukoencephalopathy is one of the serious side effects of natalizumab, risk stratification should be done.

A study of vasospasm in traumatic brain injury with subarachnoid hemorrhage

Introduction: Cerebral vasospasm (CV) is common following subarachnoid hemorrhage (SAH). However, its impact on neurological outcome, especially in head trauma, has not been yet elucidated. Controversy exists about the true relationship between TBI, SAH and Traumatic Vasospasm. Hence, this study aims to determine the association of vasospasm in TBI with SAH. Methods: This is Observational cross-sectional study with 124 head injury patients. 31 patients were excluded. Transcranial Doppler ultrasonography (TCD) was conducted on daily bases in all patients with traumatic brain injury (TBI). Vasospasm in the MCA and ACA was defined by a mean Flow velocity (FV) exceeding 120 cm/s and three times the mean FV of the ipsilateral ICA. Results: Among 93 included patients, 72 (77%) were male and 21 (23%) were female. Mean age was (35+10) years. Mean GCS score was (11+4.1). 61 (66%) patients suffered with severe head injury. Vasospasm was detected in 45 % (42) of the total patients. Vasospasm was severe among 4.3% (4 patients), and moderate among 65.6% (61 patients). Association was found between severity of trauma and the severity of vasospasm in MCA (r= 0.41 and 0.38, p value< 0.005) and in ACA (r =0.25, p value < 0.005). The presence of SAH is highly correlated with an amplified incidence of vasospasm. The patients who developed vasospasm, 55% (23) had SAH whereas 45% (19) didn’t have SAH, the corresponding p value is 0.04 which is significant. Conclusion: The high incidence of vasospasm is associated with SAH in severe TBI patients. Further studies are recommended to determine predictors of vasospasm in TBI patients with SAH.

Von Hippel-Lindau Syndrome- A Case Report

Von Hippel–Lindau (VHL) disease is a rare, familial disorder involving multiple organs, and characterized by the development of many benign and malignant tumors. It is an autosomal dominant disorder with high penetrance and variable expression. We present a case of a 31-year-old gentleman with gradual onset painless bilateral diminution in the vision for one and a half months with significant positive family history. Radiographic study revealed multiple cerebellar hemangioblastomas with obstructive hydrocephalus, renal cortical and pancreatic cysts and cystic renal cell carcinoma. Symptoms were relieved after endoscopic third ventriculostomy. These constellations of findings suggested von Hippel Lindau (VHL) syndrome and we present this case.

Message from the Chief Editor Vol.1(1)

Brain and Spine Foundation Nepal is a not-for profit organization registered (Registration No. 226156/076/077) on 13th Ashwin 2076. The Foundation aims to work with all those involved in prevention, diagnosis and treatment of brain and spine disorders and diseases. One of the guiding principle of the foundation is dissemination of medical information related to these diseases. In Nepal, there are two neurosurgical journals being regularly published Nepal Journal of Neuroscience (NJNS, ISSN 1813-1948), official journal of Nepalese Society of Neurosurgeons (NESON) and Eastern Green Neurosurgery (EGN, ISSN 2705-4470), published by Department of Neurosurgery, B and C Medical College and Teaching Hospital, Birtamode. NJNS is being published since January 2004 and EGN is being published since April 2019. However these journals accept articles mainly from neurologists and neurosurgeons. The objective of any journal is to provide information about various research projects, interaction with own fraternity and to publish scientific articles of research and clinical practice. We at the Foundation believe that the neurological problems should be tackled with multidimensional probe. We focus on awareness programs, information dissemination and involve other healthcare workers like physiotherapists, physiatrists, neuro nurses, emergency physicians, neuro-anaesthesiologists, pain physicians etc. We aim to publish this journal twice a year, on March and on September. We request all healthcare workers who take care of brain and spine patients to send articles related to their work. You can send case reports, review articles and original articles for publication in this journal.