Awake Surgery for Lesional Epilepsy in Resource-Limited Settings: Case Report and Review of Literature

Epilepsy surgery is a well-established treatment for drug-resistant epilepsy, with awake craniotomy being used in certain cases to remove epileptogenic foci while preserving crucial brain functions. We are presenting the first reported case from Pakistan of a 19-year-old woman who underwent awake epilepsy surgery to treat cortical dysplasia. She had a history of generalized tonic-clonic seizures since her childhood and was referred to our clinic due to an increase in seizure frequency. EEG and MRI identified the epileptogenic focus in the right parieto-temporal region. The patient underwent a neuro-navigation guided awake craniotomy and an excision of the epileptogenic focus in the right parieto-temporal region. The procedure was carried out using a scalp block and dexmedetomidine for conscious sedation, enabling the patient to remain awake throughout the surgery. Intraoperative mapping and electrocorticography were used for complex multidisciplinary care. Post-resection corticography showed no spikes along the resected margins. The patient was discharged without any complications and remained free of symptoms a year after the surgery. Awake epilepsy surgery is a viable option for removing epileptogenic foci while preserving vital cognitive functions. However, it is seldom used in low- and middle-income countries such as Pakistan. The successful outcome of this case underscores the need for greater awareness and availability of epilepsy surgery in resource-limited settings. Cost-effective measures, such as using small subdural strips for intraoperative localization, can be implemented.

Neurological manifestations of HIV-AIDS among HIV diagnosed patients at a tertiary Care hospital of khyber Pakhtunkhwa, Pakistan

Background: neurological manifestations affecting the nervous system at all stages of Human Immunodeficiency Virus [HIV] infection are common. Neurological complications occur in more than 40% of patients with HIV infection. They are the presenting feature of Acquired Immune Deficiency Syndrome [AIDS] in 10-20% of cases. At autopsy the prevalence of neuropathological abnormalities is 80%. Although an ongoing decline in HIV associated Central Nervous System [CNS] diseases has been observed in very recent years, the mortality from these diseases remains high

Objective: to study the type and frequency of different neurological involvements in patients with HIV infection at tertiary care hospital in Peshawar, KPK and to correlate them with CD4 counts

Study design, settings and duration: this retrospective observational study was carried at Lady Reading Hospital, Peshawar, KPK, Pakistan over a period of 8 years from May 2009 to June 2017

Subjects and Methods: a total of 100 HIV sero-positive patients of both genders, aged >18 years, showing clinical evidence of central nervous system [CNS] involvement were included. Their clinical manifestations, laboratory investigations, and neuroimaging were studied. Laboratory investigations along with magnetic resonance imaging [MRI], EEG and nerve conduction study of the brain/spine was also performed

Results: tuberculous meningitis was the most common presentation as secondary CNS illness [49%], followed by cryptococcal meningitis [16%] and cerebrovascular accidents [7%]. Furthermore, 6% had neurosyphilis, 5% had acquired immune deficiency syndrome [AIDS] associated dementia and peripheral neuropathy occurred in 17% of the patients. Headache was the most common neurological symptom seen in 42% of the patients. Seizures were noted in 35% of the patients. CD4 was significantly low in most of the patients with progressive multifocal leukoencephalopathy, HIV associated encephalopathy [HAD] and cryptococcal meningitis compared with other neurological manifestations. CD4 counts in tuberculous meningitis and HIV associated encephalopathy were 115/microl and 83/microl, respectively

Conclusion: CNS tuberculosis was the most common secondary infection seen in HIV patients followed by cryptococcal meningitis. A high index of clinical suspicion of neurological involvement in HIV patients helps in the early diagnosis and early institution of specific treatment, which in turn decreases the morbidity and mortality considerably. Early treatment and prophylaxis of neurological problems in HIV patients is very important to decrease the mortality rate

Preventive Gabapentin versus Pregabalin to Decrease Postoperative Pain after Lumbar Microdiscectomy: A Randomized Controlled Trial

STUDY DESIGN: Randomized controlled trial. PURPOSE: The purpose of this study was to compare pregabalin and gabapentin for mean postoperative visual analog score (VAS) for pain in patients undergoing single-level lumbar microdiscectomy for intervertebral disc prolapse at a tertiary care hospital. OVERVIEW OF LITERATURE: Pregabalin has a superior pharmacokinetic profile and analgesic effect at lower doses than gabapentin; however, analgesic efficacy must be established during the perioperative period after lumbar spine surgery. METHODS: This randomized controlled trial was carried out at our institute from February to October 2011 on 78 patients, with 39 participants in each study group. Patients undergoing lumbar microdiscectomy were randomized to group A (gabapentin) or group B (pregabalin) and started on trial medicines one week before surgery. The VAS for pain was recorded at 24 hours and one week postoperatively. RESULTS: Both groups had similar baseline variables, with mean ages of 42 and 39 years in groups A and B, respectively, and a majority of male patients in each group. The mean VAS values for pain at 24 hours for gabapentin vs. pregabalin were comparable (1.97±0.84 vs. 1.6±0.87, respectively; p=0.087) as were the results at one week after surgery (0.27±0.45 vs. 0.3±0.46, respectively; p=0.79). None of the patients required additional analgesia postoperatively. After adjusting for age and sex, the VAS value for group B patients was 0.028 points lower than for group A patients, but this difference was not statistically significant (p=0.817, R²=0.018). CONCLUSIONS: Pregabalin is equivalent to gabapentin for the relief of postoperative pain at a lower dose in patients undergoing lumbar microdiscectomy. Therefore, other factors, such as dose, frequency, cost, pharmacokinetics, and side effects of these medicines, should be taken into account whenever it is prescribed.

Clinically significant contrast induced acute kidney injury after non-emergent cardiac catheterization - risk factors and impact on length of hospital stay

To evaluate the frequency and risk factors associated with clinically significant contrast-induced nephropathy [CIN] in patients undergoing non-emergent coronary angiography. Descriptive study. The Aga Khan University Hospital, Karachi, from January 2005 to December 2007. Case records of patients who underwent coronary angiography with a serum creatinine of >/= 1.5 mg/dl at the time of procedure were evaluated. Clinically significant contrast induced nephropathy [CSCIN] was defined as either doubling of serum creatinine from baseline value within a week following the procedure or need for emergency hemodialysis after the procedure. One hundred and sixteen patients met the inclusion criteria. Mean age was 64.0 +/- 11.5 years, 72% were males. Overall prevalence of CIN was 17% [rise of serum creatinine by >/= 0.5 mg/dl] while that of clinically significant CIN [CSCIN] was 9.5% [11 patients]. Patients with CSCIN had significantly lower left ventricular ejection fraction [p = 0.03, OR: 0.24; 95% CI = 0.06 - 0.91] and higher prevalence of cerebrovascular disease [p < 0.001, OR: 14.66; 95% CI = 3.30 - 65.08]. Mean baseline serum creatinine was significantly higher, 3.0 +/- 1.5 vs. 2.0 +/- 1.1 mg/dl [p = 0.03, OR: 1.47; 95% CI = 1.03 - 2.11] whereas mean GFR estimated by Cockcroft-Gault formula was significantly lower at 25 +/- 7.4 vs. 41.0 +/- 14.6 ml/minute [p = 0.001, OR = 0.89, 95% CI = 0.84 - 0.95] at the time of procedure in patients with CSCIN. Mean length of hospital stay was significantly higher in this group compared to those without CIN, 9.0 +/- 5.1 vs. 3.0 +/- 3.2 days [p = 0.001, OR = 1.31, 95% CI = 1.12 - 1.54]. Multivariate analysis revealed low GFR [p = 0.001, OR = 0.88; 95% CI = 0.82 - 0.95] and low ejection fraction [p = 0.03, OR = 0.20; 95% CI = 0.04 - 0.91] to be independent factors associated with CSCIN. No significant differences were noted between the two groups in patients with hypertension, diabetes and heart failure. CSCIN is a significant concern in high risk groups despite prophylaxis. Patients with lower EF, cerebrovascular disease and low GFR at the time of procedure are more likely to have CIN.

APACHE II scores as predictors of cardio pulmonary resuscitation outcome: evidence from a tertiary care institute in a low-income country

The aim of this study was to demonstrate that APACHE II scores can be used as a predictor of the cardio-pulmonary resuscitation [CPR] outcome in hospitalized patients. A retrospective chart review of patients admitted, from 2002 to 2007, at the Aga Khan University Hospital, Karachi, was done for this study. Information was collected on 738 patients, constituting all adults admitted in general ward, ICU, CICU and SCU during this time, and who had under-went cardiac arrest and received cardiopulmonary resuscitation during their stay at the hospital. Patient characteristics, intra-arrest variables such as event-witnessed, initial cardiac rhythm, pre arrest need for intubation and vasoactive drugs, duration of CPR and survival details were extracted from patient records. The APACHE II score was calculated for each patient and a descriptive analysis was done for demographic and clinical features. The primary outcome of successful CPR was categorized as survival >24 h after CPR versus survival <24 h after CPR. Multivariable logistic regression was used to assess the association between the explanatory variables and successful CPR. Patients with APACHE II scores less than 20 had 4.6 times higher odds of survival compared to patients with a score of >35 [AOR: 4.6, 95% CI: 2.4-9.0]. Also, shorter duration of CPR [AOR: 2.9, 95% CI: 1.9-4.4], evening shift [AOR: 2.1, 95% CI: 1.3-3.5] and Male patients [AOR: 0.6, 95% CI: [0.4-0.9] compared to females were other significant predictors of CPR outcome. APACHE II score, along with other patient characteristics, should be considered in clinical decisions related to CPR administration

Complications in craniocerebral aspergillosis of sino-nasal origin in immunocompetent patients

Four immunocompetent patients of craniocerebral aspergillosis of sino-nasal origin who developed complications have been described. They developed intracerebral haemorrhages, multifocal infarctions and intraventricular dissemination of aspergillus infection and 2 patients developed acute hydrocephalus. All 4 patients have been managed by standard therapeutic regimens including both surgical resection followed by antifungal therapy while CSF shunting was done as required. Only one patient survived till the last clinical follow-up. Magnetic resonance angiography along with routine magnetic resonance imaging at the time of initial work-up may be helpful to pick up mycotic aneurysms and vascular occlusions

Pontine haemorrhage due to chondrosarcoma of the skull base

young adult presented with acute weakness of right side of body and slurring of speech. An initial brain CT scan showed a pontine haemorrhage, however MRI done a few days later revealed a mass in the left parapharyngeal space. Histopathology of the mass revealed that it was a chondrosarcoma. Subsequently the patient was initially treated with chemotherapy and radiotherapy and later surgery. Skull base chondrosarcomabe is to be included in the differentials of a young patient presenting with signs consistent with pontine haemorrhage

Quebec platelet disorder

A case of Quebec platelet disorder is hereby reported. A 33 years old woman presented with history of epistaxis and gum bleeding since childhood and menorrhagia and bleeding per vaginum after puberty, also had history of excessive blood loss after birth of child. Her coagulation profile was normal but platelet function testing by platelet aggregation assay showed abnormal aggregation of platelet with epinephrine. This type of response is seen in "Quebec platelet disorder" which is a rare autosomal dominant disorder of platelet function characterized by increased bleeding after any injury or trauma

Intracranial cavernous angiomas

To describe the clinical presentation, diagnosis, and management of patients presenting with intracranial cavernous angiomas [CAs] at a tertiary care hospital in Pakistan. Case series. Section of Neurosurgery, The Aga Khan University Hospital [AKUH], Karachi, from January 1990 to September 2008. A retrospective case note review of all patients diagnosed with intracranial CAs at AKUH during the study period. The studied variables included patient demographics, clinical presentation, family history of intracranial CAs or other space occupying lesions, modality of diagnosis, management, and outcome. Results were described as frequency percentages. During the review period, 18 patients [11 males and 7 females] were diagnosed with intracranial CAs. The median age at diagnosis was 28.5 years. The most common location of malformations was cerebrum [n=13] followed by brain stem [n=3], and cerebellum [n=2]. Nine patients had multiple lesions. Family history was present in 2 patients. Seizures and focal neurologic deficits were the main clinical manifestations. The detection rate was 93.8% with magnetic resonance imaging, but less with angiography and computerized tomography. Ten cases were treated surgically; 8 were managed conservatively. The outcome was satisfactory except for one patient, who died within 6 months of diagnosis. Surgery was performed for gross haemorrhage, rapidly increasing neurologic deficits, and intractable or long-standing seizures. Cavernomas tend to occur at younger age in females than males. This data raises a possibility of a higher frequency of multiple cavernomas in Pakistani patients. The main clinical manifestations are seizures and focal neurologic deficits. MRI is most sensitive and specific neuroradiologic modality for detecting this vascular malformation

Craniocerebral aspergillosis in immunocompetent hosts: Surgical perspective.

Craniocerebral aspergillosis is a rare but dangerous variety of central nervous system infections. Surgery is being widely recognized as the cornerstone of management. Due to the rarity of the disease, difficulty and delay in diagnosis and poor outcome, there is very little in the literature regarding the various surgical strategies that may be adopted in these patients. Early aggressive surgery followed by chemotherapy offers the best chances. Surgical planning would depend upon the type and location of the disease process as well as the condition of the patient. Perioperative care holds immense importance and knowledge of possible complications is essential. Aspergillosis of the central nervous system is difficult to diagnose and equally difficult to treat. Surgery remains the cornerstone of management followed by systemic antifungal medications. Results are better in immunocompetent patients as compared to those who are immunocompromised.

Role of surgery in cerebral venous sinus thrombosis

Cerebral venous sinus thrombosis [CVST] usually is taken care of by medical management or neuro-interventional vascular techniques. Some cases of CVST may take a malignant course if the intracranial pressure increases excessively. This increase in pressure is because of oedema in brain tissue due to impediment in venous return and/or intracerebral haemorrhage. Neurosurgical experience has shown remarkable recovery in these moribund patients if appropriate surgical intervention is done within reasonable time. Emergent decompressive craniotomy or other neurosurgical interventions are the only appropriate treatment in these malignant forms of CVST to prevent mortality and severe morbidity

Dural metastases presenting as an extradural hematoma: a rare presentation

We report a case of an elderly man who presented with hemiparesis and plain CT scan findings highly suggestive of an extradural hematoma as the underlying cause. This patient was later found to have dural metastases secondary to bronchogenic carcinoma. Dural metastases are rare, usually presenting as dural mass, but may also present as chronic subdural or extradural hematoma on non contrast CT scan, leading to an erroneous diagnosis in the unsuspecting