Spectrum of trigeminal neuralgia

Trigeminal neuralgia [TN] is a very painful condition characterized by paroxysmal shock like pain in the distribution of one or more branches of trigeminal nerve caused by neurovascular conflict at the root entry zone of trigeminal nerve. This study was conducted to analyse the demography and pattern of TN in our setup. This descriptive study was conducted in the Oral Surgery unit, Department of Dentistry, Ayub Medical College, Abbottabad, from April 2009 to October 2011. A total of 117 patients were included in study by convenience [non probability] sampling technique. All the patients presenting with the clinical features of TN were included in study. Out of 117 cases, 49 [41.9%] were males and remaining 68 [58.1%] were females. Age of the patients ranged from 32-72 [53.90 +/- 10.21] years. Right side was involved in 63 patients [53.8%], while the left side was involved in 51 patients [43.6%]. In only three cases [2%] there was bilateral involvement. The maxillary division was involved in 68 cases [58.1%] and mandibular division was involved in 37 cases [31.6%]. The most common site of involvement was infra-orbital, which was involved in 68 cases [58.11%]. The next common site was the mental nerve which showed involvement in 35 cases [29.9%] followed by inferior alveolar nerve which was affected in 14 cases [12%]. Thirty three [28.2%] patients were having mild pain, 54 [46.2%] patients having moderate, 21 [18%] patients with severe and 9 [7.7%] patients were having very severe pain. No patient in our study had a family history of TN. Among our patients 103 [88%] patients underwent dental extraction for the same pain. The incidence of TN is more in old age especially in females. TN is frequently misdiagnosed in with tooth ache, so there is need to educate the medical practitioners and masses in order to avoid un-necessary tooth extractions

Frequency of conservatively managed traumatic acute subdural haematoma changing into chronic subdural haematoma

Traumatic brain injury represents a significant cause of mortality and permanent disability in the adult population. Acute subdural haematoma is one of the conditions most strongly associated with severe brain injury. Knowledge on the natural history of the illness and the outcome of patients conservatively managed may help the neurosurgeon in the decision-making process. We prospectively analysed 27 patients with age ranges 15-90 years, in whom a CT scan diagnosis of acute subdural haematoma was made, and in whom craniotomy for evacuation was not initially performed, to the neurosurgery department of Ayub Teaching Hospital Abbottabad [2008-2011]. Patients with deranged bleeding profile, anticoagulant therapy, chronic liver disease, any other associated intracranial abnormalities, such as cerebral contusions, as shown on CT, were excluded from this study. All patients were followed by serial CT scans, and a neurological assessment was done. There were 18 male and 9 female patients, Cerebral atrophy was present in over half of the sample. In 22 of our patients, the acute subdural haematoma resolved spontaneously, without evidence of damage to the underlying brain, as shown by CT or neurological findings. Four patients subsequently required burr hole drainage for chronic subdural haematoma. In each of these patients, haematoma thickness was greater than 10 mm. The mean delay between injury and operation in this group was 15-21 days. Among these patients 1 patient required craniotomy for haematoma removal due to neurological deterioration. Certain conscious patients with small acute subdural haematomas, without mass effect on CT, may be safely managed conservatively, but due to high risk of these acute subdural haematoma changing into chronic subdural haematoma these patients should be reinvestigated in case of neurological deterioration.

Outcome of transcranial repair of traumatic csf rhinorrhea

Traumatic brain injury represents a significant cause of mortality and permanent disability in the adult population. Posttraumatic CSF rhinorrhea is one of the conditions most strongly associated with severe brain injury. Knowledge on the natural history of the illness and the outcomes of patients with transcranial subfrontal approach for posttraumatic CSF rhinorrhea approach may help the neurosurgeon in the decision-making process. This study was conducted to analyse the outcome of trans-cranial sub-frontal approach for traumatic CSF rhinorrhea, with duroplasty and fibrin glue. This study was carried out in the Department of Neurosurgery, Ayub Medical College, Abbottabad from Jan 2007 to Jun 2011. All patients undergoing trans-cranial sub-frontal repair of traumatic CSF fistulas were included. Where possible primary dural repair was performed under hypotensive general anaesthesia and in the cases where it was not possible, graft was used. This was followed by application of fibrin glue at the repaired site. Graft materials used in this study were taken from fascia lata, pericranium, and temporalis fascia. Out of 27 patients 21 were men and 6 were women. Age of the patients ranged from 17 to 56 [34.5 +/- 4.6] years. Main causes of trauma were road traffic accidents [23, 85%], fall from height [3, 11%], and assaults [1, 4%]. In 23 [85%] cases no CSF leak was observed in immediate postoperative period as well as during the follow-up visits while in 3 [11%] cases additional lumber punctures were required to augment the repair. One patient failed to respond to surgery and lumbar drainage. The CSF rhinorrhea is commonly seen in patients with anterior skull fractures secondary to head injury. Initially conservative trail should be given to the patients, if it fails then on-lay dural technique followed by fibrin glue application through transcranial approach has good outcome with less chances of complications.

Efficacy of endoscopic third ventriculostomy in noncommunicating hydrocephalus

Hydrocephalus is common problem requiring either extra-cranial [shunts] or intracranial [ventriculostomy] diversion of cerebrospinal fluid. Endoscopic third ventriculostomy obviates all the complications of shunts and has been accepted as the procedure of choice for the treatment of obstructed hydrocephalus in adults and children because of the minimally invasive nature. This study was conducted to determine the efficacy of endoscopic third ventriculostomy in the treatment of noncommunicating hydrocephalus. This cross sectional descriptive study was done in neurosurgery department of Hayatabad Medical Complex, Peshawar, from 2[nd] February 2011 to 1[st] march 2012. A total of 171 patients with non-communicating hydrocephalous, irrespective of gender discrimination and Glasgow coma scale score of 10 and above were included in this study. Patients below one year of age, with lesion in the floor of the third ventricle or near basilar artery, and hydrocephalus with infected CSF or haemorrhage were excluded. Hydrocephalous was diagnosed on CT-scan brain. All the patients were followed up till 72 hours post-operatively for the determination of effectiveness in terms of improvement in Glasgow coma scale by at least 2 points. All the above mentioned information including name, age, gender and address were recorded in a predesigned proforma. The data was analysed using SPSS-17. Frequency and percentage was calculated for categorical variables. Mean +/- SD was calculated for age. A total of 171 patients with noncommunicating hydrocephalous were included in the study. Out of 171 patients, there were 104 [60.8%] males and 67 [39.2%] females. Age ranged from 1-70 years with majority of the patients was below 10 years of age. Majority of the patients had hydrocephalus due to tuberculous meningitis 39.2% of the whole. In 134 [78.4%] patients the procedure was effective. Procedure was more effective in hydrocephalus due to space occupying lesion. Endoscopic third ventriculostomy is a very effective procedure for the treatment of non-communicating hydrocephalus.

Transnasal endoscopic repair if cerebrospinal fluid rhinorrhoea

Background: Cerebrospinal fluid [CSF] leaks can arise as a complication of trauma, hydrocephalus, endoscopic sinus surgery or it may occur spontaneously without any identifiable cause. Surgical repair is recommended in patients who do not respond to the conservative management. In recent years transnasal endoscopic approach has become the preferred method for repairing the CSF leaks and better outcomes have been reported as compared to the intracranial approaches that were previously used. Objective of this study was to analyse the outcome of transnasal endoscopic repairof CSF rhinorrhoea. Methods: This prospective study was conducted in the Department of Neurosurgery, Ayub Medical College, Abbottabad, from March 2007 to March 2010. Twenty-one patients with CSF rhinorrhoea were included in study that were diagnosed on the basis of clinical evaluation, glucose concentration of nasal discharge, computed tomography [CT] and magnetic resonance imaging [MRI]. These patients did not respond to conservative management and were operated transnasally using rigid endoscope. Patients were followed up for a mean duration of 9 months and the outcome was analysed. Results: The patients included in the study ranged in the age group of 12–55 years. Among the patients 13 [57%] were female and 8 [38%] were males. The cause of CSF rhinorrhoea was traumatic in 16 [76.19%], Idiopathic or spontaneous in 4 [19.04%] and 1 [4.7%] case was related to endoscopic surgery for pituitary macroedenoma. In 10 [47.6.8%] patients the site of leak was cribriform plate, 5 [23.8%] had from sphenoid, 4 [19.04%] from frontal sinus and in 2 [9.5%] Ethmoid was affected. Primary surgery was successful in 17 [80.95%] of cases. In 2 [9.5%] cases re-exploration had to be performed. In 1 patient re-exploration had to be done for the third time. Overall success rate was 95%. One patient presented with CSF leak and meningitis 1 month after surgery and unfortunately died. Conclusion: Transnasal endoscopic repair of CSF rhinorrhoea is highly successful, safe and less traumatic. Keywords: Transnasal endoscopic repair, CSF Rhinorrhoea, CSF leak, transnasal endoscopic duroplasty