Management of cerebrospinal fluid leak following posterior cranial fossa surgery

Objective: Cerebrospinal fluid leakage remains a significant cause of morbidity following posterior fossa surgery, and its treatment remains a difficult problem. The aim of the study was to propose a treatment algorithm for its management

Methods: A retrospective, single-center study was conducted on 147 patients who underwent elective posterior fossa surgery for a variety of diseases. Patients with post operative CSF leakage had either been treated initially with conservative measures including re-suturing of the wound, with CSF lumbar drainage to be employed in case the CSF leakage didn't stop, or the initial intervention was the institution of CSF lumbar drainage simultaneously with conservative measures. VP [ventriculo-peritoneal] shunt was done in patients with gross hydrocephalus on postoperative CT brain

Results: There were 25 [17%] cases of CSF leakage, including 24 incisional CSF leaks and one case of CSF otorrhea. In eight patients with incisional CSF leakage treated initially with conservative measures including re-suturing of the wound, CSF leakage stopped in only two cases. CSF lumbar drainage instituted later on in six cases with persistent leakage stopped the CSF leakage. In fourteen patients managed initially with re-suturing of the wound and concomitant CSF lumbar drainage, CSF leakage settled in all the cases. Two patients with gross hydrocephalus on post operative CT were managed successfully with VP shunt. Re-suturing of the wound with concomitant CSF lumbar drainage was found to be significantly associated [p=0.003] with the stoppage of CSF leakage, and the settlement of meningitis [p= 0.014]

Conclusion: Incisional CSF leaks after posterior fossa surgery should be managed with re-suturing of the wound and concomitant CSF lumbar drainage, instead of an initial trial of conservative therapy alone

Surgical outcome of anterior decompression, grafting and fixation in caries of dorsolumbar spine

Objective: To evaluate the surgical outcome of anterior decompression, grafting and fixation in tuberculosis of the dorsal and lumbar spine with compression over the neural tissue and neural deficit

Study Design: A case series

Place and Duration of Study: Department of Neurosurgery Unit-I, Lahore General Hospital, Lahore, from January 2008 to March 2012

Methodology: Patients with caries spine having compression over the thecal sac with neurological deficit and kyphosis were included in the study. Patients below 17 years and above 56 years of age; those with bed sores and unfit for anesthesia were excluded from the study. Complete blood picture with ESR, X-rays of chest and of the relevant spinal level, and MRI were done. All patients were treated with corpectomy, debridement, drainage of abscess and grafting followed by fixation with poly-axial screws and rods. All patients were assessed by ASIA Impairment Scale before and after surgery and with Bridwell grading after surgery

Results: Among 79 patients, 47 were males and 32 females. The mean age was 35.97 +/- 8.8 years. The commonest level involved was the dorsolumbar junction [n=42, 53.16%]. Lower limb power improved to ambulatory level in 60% of patients with complete paraplegia; recovery was excellent in patients with partial weakness; only 2 patients [2.53%] deteriorated to a lower grade. There was no postoperative mortality. One patient had long ICU stay due to lung injury

Conclusion: Corpectomy followed by grafting and fixation is safe and effective procedure for dorsolumbar spinal caries. Even those patients presenting with complete paraplegia showed improvement in motor power to ambulatory level and those who had partial deficit showed excellent improvement

Chondroma of cerebral falx: a rare intracranial diagnosis

Chondromas are benign tumors which mostly occur in extremities but also sometimes in the cranium. Intracerebral chondroma is rare condition. Most intracranial chondromas arise from skull base, but chondroma of falx origin is a rare entity and mostly occurs in relation with syndromic disorders such as Mafucci's syndrome or Ollier's syndrome. Here, we report a rare case of falcine intracranial chondroma in a young man who presented with headaches and weakness of lower extremities and no signs of any syndromic disorder. The purpose of this case report was to raise awareness about intracranial chondromas. Chondroma should be considered in the differential diagnosis of calcified masses arising from the falx

Aneurysmal subarachnoid hemorrhage: outcome of aneurysm clipping versus coiling in anterior circulation aneurysm

Objective: To compare the neurological outcome of microsurgical clipping versus coiling in patients with anterior circulation aneurysm

Study Design: Comparative study

Place and Duration of Study: Department of Neurosurgery, Lahore General Hospital, Lahore, from January 2010 to December 2013

Methodology: Patients aged 14 - 60 years, with ruptured cerebral aneurysm of anterior circulation and World Federation of Neurosurgical Society [WFNS] grades 1, 2 and 3 were included. Patients more than 60 years, medically unfit patient and posterior circulation aneurysms and WFNS grades 4 and 5 were excluded. Aneurysm sac obliteration was done in randomized manner with microsurgical clipping or coiling. Postoperatively, the patients were assessed and followed-up upto one year for outcome parameters on the bases of WFNS grade and Modified Ranking Scale [mRS] as favourable [mRS 2]

Results: Among 140 subjects selected for study, 70 were included in group A, i.e. coiling and other 70 were in group B, i.e. clipping. The median age of patients in group A was 52.5 +/- 10 years and in group B was 51.00 +/- 10 years. Overall, 56 [40%] males, 28 [60%] males in each group; and 84 [60%] females, 42 [60%] in each group were included. The male to female ratio in this study was 1:1.5. In group A, i.e. coiling, 27 [38.6%] patients had no disability [grades 1 and 2], 25 [35.7%] were slightly disabled [grade 3] and 18 [25.7%] had moderate disability [grade 4]; whereas in group B, i.e. clipping group 23 [32.9%] patients had no disability [grades 1 and 2], 23 [32.9%] were slightly disabled [grade 3] and 24 [34.3%] had moderate disability [grade 4]. At one year follow-up, in group A, favourable outcome was achieved in 56 [80%] of patients compared to 48 [68.6%] in group B; whilst, 14 [20%] patients in group A and 22 [33.1%] in group B showed unfavourable outcome. Although mortality rate was higher in clipping [n=3, 4.3%] as compared to coiling [n=1, 1.4%], but was not statistically significant [p = 0.310]

Conclusion: Endovascular coiling of anterior circulation aneurysms is safe and as effective and successful as aneurysm clipping and is less invasive also

Aneurysmal subarachnoid haemorrhage: outcome of aneurysm clipping in elderly patients and predictors of unfavourable outcome

To determine the outcome of treatment of microsurgical clipping in elderly [60 - 70 years] patients with aneurysmal subarachnoid hemorrhage and determine the predictors of poor outcome. Longitudinal analytical study. Nishtar Hospital, Multan, Mayo Hospital, Lahore, Department of Neurosurgery, Lahore General Hospital, Lahore, from January 2000 to January 2010. Elderly patients [60 - 70 years] with ruptured cerebral aneurysm were enrolled and graded on the basis of World Federation of Neurosurgeons Scale [WFNS]. Aneurysm sac obliteration was done in all the patients with microsurgical clipping. Postoperatively, the patients were assessed upto 3 months for outcome parameters i.e., neurological deterioration [based on WFNS grade and modified Rankin scale as favourable [mRS score <-2] and unfavourable [mRS score > 2]. The factors associated with unfavourable outcome were also noted which included age > 65 years, poor initial WFNS grade, and the occurrence of ischaemia. The mean age of the 48 patients was 65 +/- 5.45 years. There were 31 [64.6%] male and 17 [35.4%] female patients. Postprocedural neurological deterioration occurred in 23 patients [47.9%] related to ischaemia in 14 [29.16%], rebleeding in 1 [2%], and hydrocephalus in 8 [16.66%]. At 03 months, the outcome was favourable in 25 patients [52.08%] and unfavourable in 23 [47.91%]. In old patients, careful pre-operative assessment, interdisciplinary approach and meticulous tissue handling during aneurysm clipping may decrease the unfavourable outcome