Dengue hemorrhagic fever: A rare cause of pituitary tumor hemorrhage and reversible vision loss.

Dengue hemorrhagic fever leading to hemorrhage in pituitary adenoma is not reported till date: We herein report the first case of bilateral visual loss secondary to pituitary adenoma hemorrhage associated with dengue hemorrhagic fever. Urgent transnasal trans sphenoidal decompression of the macroadenoma prevented permanent visual loss in this patient. Pituitary apoplexy should be considered as differential diagnosis of visual deterioration apart from retinal hemorrhage, maculopathy, and optic neuropathy in cases of dengue hemorrhagic fever. Early decompression of optic nerves helped in the restoration of vision.

Economics of head injuries.

Head injuries account for significant proportion of neurosurgical admissions and bed occupancy. Patients with head injuries also consume significant proportions of neurosurgical resources. A prospective 6-month study has been carried out to evaluate the expenditure incurred on head injury patients in a modern neurosurgical center equipped with state of the art infrastructure. Costing areas included wages / salaries of health care personnel, cost of medicines / surgical items / crystalloids, general store items, stationary, all investigation charges, equipment cost, overhead building cost, maintenance cost, electricity and water charges and cost of medical gases, air conditioning and operation theatre expenses. Expenditure in each area was calculated and apportioned to each bed. The statistical analysis was done using X2 test. The cost of stay in ward was found to be Rs. 1062 / bed / day and in neurosurgical ICU Rs. 3082 / bed / day. The operation theatre cost for each surgery was Rs. 11948. The cost of hospital stay per day for minor, moderate and severe head injury group was found to be Rs. 1921, Rs. 2569 and Rs. 2713 respectively. The patients who developed complications, the cost of stay per day in the hospital were Rs. 2867. In the operative group, the cost of hospital stay per day was Rs. 3804. The total expenditure in minor head injury was Rs. 7800 per patient, in moderate head injury was Rs. 22172 per patient, whereas in severe head injury, it was found to be Rs. 32852 per patient. Patients who underwent surgery, the total cost incurred was Rs. 33100 per operated patient.

Recurrent lymphocytic hypophysitis in a woman 27 years after subtotal adrenalectomy for hypercortisolism possibly of autoimmune origin.

Lymphocytic hypophysitis commonly occurs in females in peripartum period but several unusual presentations have been reported. Here we report a rare case of recurrent lymphocytic hypophysitis in a woman who had subtotal adrenalectomy for hypercortisolism 27 years back. Polyglandular autoimmune endocrinopathy with an uncommon combination of Cushing's syndrome and recurrent hypophysitis is a strong possibility in this case. Treatment with steroids has been found to have beneficial effect.

Role of shunt surgery in pediatric tubercular meningitis with hydrocephalus.

This study was designed to evaluate the indications for ventriculoperitoneal shunting in cases of children with tubercular meningitis, presenting with hydrocephalus. Thirty seven children (less than 18 years of age) of tubercular meningitis with hydrocephalus (TBMH) who underwent ventriculoperitoneal shunting over a three year period (1999 to 2001) were included in the study. Sixteen (43%) children were Palur stage II, 15 (40%) stage III, and 6 (16%) stage IV. Fifteen (40%) children had received antitubercular therapy for less than 4 months and 17 (46%) received therapy for more than 4 months prior to presentation. Five (14%) children had not previously received antitubercular therapy. Shunt related complications occurred in 11 (30%) children and 3 children had undergone revision of the shunt multiple times. Good outcome was seen in 16 (43%) children. Thirteen (35%) had moderate disability and 6 (16%) had severe disability at 3 months of follow up. 62% (n =10) children in grade II had a good outcome compared to 40% (n = 6) in grade III. All six children in grade IV had a poor outcome. 2 children, both having multiple infarcts, died and the remaining 4 were left with severe disability. We recommend shunt placement in all children of grade II and III TBMH as this policy has yielded the best results. For grade IV children external ventricular drainage, followed by shunting if improvement occurs remains the most cost-effective procedure.

Giant intraparenchymal neurocysticercosis: unusual MRI findings.

We report a case of surgically proven giant neurocysticercosis (NCC). MR imaging revealed an unusually large solitary parenchymal cystic lesion showing signal intensity similar to CSF on all pulse sequences, with internal septations and a small nodule in the anterior aspect of this lesion compatible with this diagnosis. Identification of a scolex in a cystic lesion with CSF intensity plays a key role in the diagnosis of NCC. The presence of internal septations is an atypical feature.

Efficacy and results of expansive laminoplasty in patients with severe cervical myelopathy due to cervical canal stenosis.

AIMS AND OBJECTIVES: To assess the efficacy and results of expansive laminoplasty in advanced (Nurick's Grade III or greater) cervical myelopathy. MATERIALS AND METHODS: We reviewed data in 24 patients who underwent cervical laminoplasty from January 1999 to December 2002. Nuricks grading was used for quantifying the neurological deficits and outcome analysis was done using Odom's criteria. A modified Hirabayashi's open door laminoplasty was done using Titanium miniplates and screws in 22 patients, autologous bone in one and hydroxyapatite spacer in one patient. OBSERVATIONS: There were 3 females and 21 males with a mean age of 56 years (range 39-72 years). Four patients presented in Nuricks Grade III, 15 in Grade IV and five in Grade V. MR imaging showed MSCS in 21 cases, OPLL in nine cases and ligamentum flavum hypertrophy in nine cases with cord signal changes being present in 19 cases. RESULTS: All patients with duration of symptoms less than three years, and 50 % with duration ranging from three to six years had improvement by at least one Nurick's grade following surgery. Eighty-seven per cent Grade IV patients (ambulatory with support) improved to Grade III (ambulatory without support) following laminoplasty. Using Odom's criteria, 23 patients (95.8%) had a good to fair outcome. CONCLUSIONS: Cord decompression with expansive laminoplasty using titanium miniplate fixation may improve the neurological outcome even in patients presenting late, and improvement by even one grade may have major 'quality of life' benefits for these patients.

Foramen magnum tumors: a series of 30 cases.

BACKGROUND AND AIMS: Foramen magnum tumors, especially those located ventrally, are surgically challenging. We studied clinical and surgical details of extramedullary tumors located in the region of the foramen magnum. MATERIAL AND METHODS: A series of 30 cases of extramedullary tumors at the foramen magnum, operated over a period of 8 years is presented. RESULTS: There were 10 neurofibromas, 8 meningiomas, 6 chordomas, 2 tuberculomas and 4 miscellaneous tumors. The clinical profile consisted of sensory symptoms in all the patients, quadriparesis in 24, lower cranial nerve affection in 8 and sphincter disturbances in 6 patients. The surgical approaches consisted of an extreme lateral approach in 10, a posterior or posterolateral approach in 18 and a per-oral route in 2 cases. Total excision of the tumor was performed in 24 and a subtotal excision of the tumor was done in 6 cases. Two patients died, one due to meningitis and the other due to chest infection. Eight other patients had complications like CSF leak, meningitis, pseudomeningocele, laryngeal edema, and transient worsening of neurological deficits. CONCLUSIONS: Foramen magnum tumors have long been regarded as difficult lesions both in terms of diagnosis and management. However, with the availability of MR imaging, newer surgical techniques and skull basal exposures, the excision of these lesions is becoming easier and safer.

Fenestration of the posterior communicating artery.

A 21-year-old male presented with sudden onset of right-sided third nerve paresis. Angiogram showed a fenestrated posterior communication artery on the right side and no other vascular anomalies. There was no other lesion that could suggest a cause for the third nerve weakness. Fenestration of the posterior communicating artery has not been reported till date. The case is discussed and the literature on the subject is reviewed.

Giant vertebrobasilar junction aneurysms: unusual cases.

Giant vertebrobasilar (VB) junction aneurysms are uncommon aneurysms, especially those associated with multiple aneurysms of the posterior circulation. We report two cases, one with a small and a giant aneurysm of the VB junction which were surgically clipped; and the other with a small left anterior inferior cerebellar artery (AICA) aneurysm which resolved spontaneously. The patient, however, developed a de-novo giant VB junction aneurysm, which was detected on a follow-up angiogram. This aneurysm was treated by surgical clipping. The clinical features, angiographic considerations and surgical treatment of such rare conditions are discussed and the relevant literature reviewed.

Subarachnoid hemorrhage and intracereebral hematoma following lumboperitoneal shunt for pseudotumor cerebri: a rare complication.

Placement of lumboperitoneal (LP) shunt as a surgical treatment for benign intracranial hypertension (BIH) is generally a safe procedure, with complications like mechanical failure, overdrainage and infections. Subarachnoid hemorrhage and intracerebral hematoma were seen after lumboperitoneal shunt in a patient having BIH. These complications were the cause of the patient's deterioration. After removal of the hematoma and performing a decompressive procedure, patient's neurological condition improved. The clinical features, investigations and clinical course are described and the literature reviewed.

Obstetric brachial plexus palsy: a clinical and electrophysiologic evaluation.

BACKGROUND: Obstetrical brachial plexus palsy (OBPP) occurs as sequelae of birth-related trauma, antenatal and parturition related complications. It is associated with varying degrees of functional disability. Electrodiagnostic studies (EDS) are an adjunctive tool and help to localise and prognosticate the outcome of OBPP. METHODS: Fourteen children, presenting with OBPP to the Clinical Neurophysiology Lab, were analyzed. Details of birth history were obtained, and EDS were performed to characterize the lesion. RESULTS: The age ranged from one month to one year. Ten had unilateral and four bilateral brachial palsy. On EDS, five had pan-plexus, six predominantly upper plexus and three lower plexus involvement. A poor re-innervation pattern on EMG correlated with inadequate recovery. CONCLUSION: OBPP, a condition associated with considerable disability, needs to be prevented. Electrodiagnostic studies are a useful adjunctive tool for characterizing the site of injury and prognostication.

Microneural anastomosis with fibrin glue: an experimental study.

An experimental study was designed to compare the histological analysis of nerve anastomosis with 10-0 microsurgical sutures and fibrin adhesive. Wistar albino rats' sciatic nerves were transected and repaired either with fibrin adhesive-Beriplast P (M/s Centeon-Cadila Health Care) or with 10-0 monofilament microsutures. Histological assessment was performed at 10, 20, 30, 60 and 90 days after surgery. Functional recovery of the sciatic nerves started at two months and was near normal by three months. Separation of the stumps did not occur in any of the glued nerves. Histological evaluation showed no appreciable difference in the outcome of nerve regeneration after microsurgical repair using sutures or fibrin tissue adhesive. However, inflammation and granuloma formation were appreciated at the suture site, which presented a focal hindrance to myelin and axonal regeneration. Fibrin glueing is attractive for clinical purposes, since it is simpler and less time consuming than suturing.

Role of emergency surgery to reduce mortality from rebleed in patients with aneurysmal SAH.

Potentially salvageable patients with aneurysmal subarachnoid hemorrhage may rebleed and die after admission to a hospital, awaiting an angiogram or surgery. In an attempt to reduce the number of patients thus lost, we are operating on such patients on an emergency basis. This report is a retrospective analysis of patients operated early after aneurysmal SAH, but during routine working hours, versus patients operated on an emergency basis. During an 18 month period 109 patients underwent surgery for intracranial aneurysm. Fifty two (Group 1) patients were subjected to emergency clipping of the aneurysm, and 57 (Group 2) patients underwent early clipping but during routine working hours. There was no selection bias between the two groups. Another 10 patients in Hunt and Hess Grade II and III rebled and died, after admission, awaiting an angiogram or surgery. The overall mortality for the two groups (Grade I to IV) was 11.9%. Mortality in Groups 1 and 2 was 9.6% and 14.0% respectively. At 1 month, good outcome was recorded in 86.6% patients in grade I, 69.2% patients in grade II and 42.8% patients in grade III in group I compared to 68.7% patients in grade I, 80% patients in grade II and 31.5% patients in grade III in group 2. However, the difference was not statistically significant. There was also no significant difference between the incidence of intraoperative brain swelling and delayed ischaemic neurological deficit between the two groups. Grade IV patients had a poor outcome in both the groups. Angiographic vasospasm was associated with poor out come, in either group, in grade IV patients. Patients in Grades I to III should undergo emergency surgery, if the surgeon is experienced and willing to operate at odd hours and necessary support facilities of neuroradiology and neuroanaesthesiology are available. This would avoid deaths in patients awaiting angiograms or surgery.

Development of neurogenic pulmonary edema at different grades of intracranial pressure in cats.

Development of neurogenic pulmonary edema (NPE) subsequent to increased intracranial pressure (ICP) was evaluated in an experimental model in cats. Experiments were conducted in chloralose anaesthetised animals, either on spontaneous respiration or on intermittent positive pressure ventilation. Hemodynamic parameters i.e., mean arterial pressure (MAP) and heart rate (HR) were continuously monitored. Pulmonary artery/right ventricular systolic pressure was recorded in cats on spontaneous respiration. Increase in ICP for 180 minutes caused an increase in extravascular lung water (EVLW) content in both spontaneously breathing and artificially ventilated animals. In spontaneously breathing animals EVLW to blood free dry weight ratio (EVLW/BFDW) was 3.95 +/- 0.16 and 4.96 +/- 0.16 at ICP 40 and 80 mm Hg respectively while in animals on artificial ventilation, at 40, 60, 80 and 100 mm Hg ICP, it was 3.88 +/- 0.11, 4.09 +/- 0.10, 4.50 +/- 0.13 and 5.03 +/- 0.17 respectively. These values were significantly greater (P < 0.05) as compared to that in sham operated animals (3.43 +/- 0.10). This was accompanied by rise in MAP, HR and pulmonary artery pressure. The study establishes the graded development of NPE, the severity of which is proportional to the levels of ICP.