Craniopharyngioma total or near total surgical resection: an outcome based learning experience

Background: Craniopharyngiomas are benign slow growing tumours that are located within the sellar and para sellar region of the central nervous system. It is a rare but significant health problem in Pakistan. The point prevalence of this tumour is approximately 2/100,000

Objective: To determine the outcome of complete resection in patients with craniopharyngioma and to determine the relationship of different factors with outcome at 3 months of follow up

Methods: A case series study conducted in thirty five patients, who were diagnosed as cases of craniopharyngioma on the basis of history, clinical examination, CT and MRI appearances and histopathological examination. All patients underwent complete resection of craniopharyngioma. The study was conducted at the Department of Neurosurgery, Dow University of Health Sciences/ Civil Hospital, Karachi from 27th December, 2006 and 27th December, 2007

Results: Good outcome was seen in thirty four [97%] patients, one [3%] had poor outcome in term of mortality. Age, Preoperative presence of neurological deficit, localization of the lesion and preoperative hydrocephalus just before placement of VP shunt and radical excision were the most important predictor of good outcome. The rest of factors studied such as Glassgow coma, duration of illness, and signs of meningeal irritation postoperative hydrocephalus had no effect on outcome

Conclusion: A complete excision of the tumour is recommended, if there is no hypothalamic invasion and in the presence of hypothalamic invasion, near total resection with post-operative radiotherapy. Endocrine disturbances need careful follow up and replacement

Current consideration regarding operative versus non-operative outcome of brain contusion patients

Background: Brain contusion surgeries versus conservative treatment are considered to be the typical decisions faced by doctors, resolved usually based on the experience of respective departments. Till date there are no standard guidelines regarding conservative versus surgical management

Objectives: To determine the outcome of the surgical and medical management in posttraumatic brain contusion patients

Methods: The study was conducted on patients having small and large brain contusions admitted in the department were selected through custom Proforma. The 41 patients [31 males 10 females] included corresponded to no specific exclusion criteria. The patients who improved by Glasgow coma score, neurologically or resolution was confirmed by Computed tomography scan brain were categorized under conservative management. While the patients, who deteriorated by Glasgow coma score, neurologically, bradycardia or showed expansion in the size of contusion with mass effect underwent standard decompressive craniotomy or cranectomy and evacuation of contusions along with duroplasty. Complications and improvement of the patients were determined at follow up and monitored by the help of interval brain CT scan during their stay in the department subsequently followed by cranioplasties

Results: There was a male predilection with male to female ratio of 3.1:1. The age group more frequently affected was 20-40 years and the most causative agent was road trauma accident. Complications were found among two patients as intractable seizures, brain abscess formation, hydrocephalus and post operative jaundice in one patient each. Wound infections in four patients. Overall outcome was good in conservative and surgical intervention patients of brain contusions. The total mortality was four patients, two in each group of patients

Conclusion: Therefore we recommend that nonsurgical and surgical management has comparable results, but surgical decompressive craniotomy is the mainstay of treatment based on the essential monitoring tools as repeated interval scanning and neurological evaluation considering the timing of surgery, volume and size of hematoma, conscious status, bradycardia and hypertension

Outcome of open transcortical approach in the management of intraventricular lesions

To evaluate the outcome of management of intraventricular lesions operated by an open transcortical [nonendoscopic] approach. Case series. Department of Neurosurgery, Dow University of Health Sciences and Civil Hospital, Karachi, from January 2009 to December 2011, with six months follow-up. All cases with lesions in the lateral ventricle and anterior third ventricle operated by open transcortical approach, were included after informed consent. Total excision of the lesion was attempted in all cases. Patients were analyzed for outcome in terms of establishment of diagnosis, completeness of resection, morbidity and mortality. A total of 33 patients were operated. Twenty three were males and 10 were females. Colloid cyst was diagnosed in 14 patients [42%], giant cell astrocytoma and choroid plexus papilloma in 4 cases each and subependymoma and central neurocytoma in 2 cases each, epidermoid, choroid plexus carcinoma, oligodendroglioma, metastasis, meningioma, ependymoma and cavernous hemangioma in one patient each. The overall outcome could be labeled as good in 24 out of 33 cases [73%] and in 8 cases [24%] it was fair. One patient died due to ventriculitis and was categorized as poor outcome [3%]. Postoperative complications included meningitis, seizures, intraventicular haemorrhage, subdural collection and transient hemiparesis. Nine patients had persistent hydrocephalus requiring ventriculoperitoneal shunt. Conventional open transcortical approach is still effective in getting conclusive biopsy or near total excision of the lesion with minimum morbidity.