Subdural hydatid cyst presenting as recurrent subdural hygroma.

Intracranial hydatid disease is an uncommon entity that usually is parenchymal in location. Presence of hydatid cyst in subdural location is being reported for the first time in the literature. A 13-year-old female child with the diagnosis of hydatid disease of brain was operated. She was advised to take albendazole which she did not take. In postoperative period she developed recurrent subdural hygroma for which multiple surgical interventions were done and finally cause of recurrent subdural hygroma was found to be hydatid cyst in the subdural space. The patient had initially undergone craniotomy for the excision of hydatid cyst. Later on she developed subdural hygroma for which the burr hole drainage was done twice. At time of third recurrence subduro-peritoneal (SDP) shunt was done. When she had recurrence again along with hydrocephalus, than VP shunt and revision of the SDP shunt was planned. While doing revision of SDP shunt, hydatid cyst was seen emerging from the burr hole site. A craniotomy was done to remove the hydatid cyst from the subdural space. Since then there has been no recurrent collection. Complete surgical excision is the best treatment modality to treat hydatid cyst of brain. Accidental spillage of the contents can have lead to recurrence, so every effort must be taken to prevent spillage of contents. Postoperatively all the patients must be put on antihelminthics.

Combination of needle aspiration and core needle biopsy: A new technique of stereotactic biopsy.

AIM: The study aims at describing the results of using a new technique to acquire the tissue sample in stereotactic biopsy of brain lesions. MATERIALS AND METHODS: The study was performed in 19 patients over a period of 5 years in which we used the new technique, i.e., Abrar and Afzal technique (AT) of obtaining tissue biopsy. It is a combination of core tissue biopsy and needle aspiration techniques. The technique was devised to acquire greater amount of tissue for pathologic study. RESULTS: While we could give pathologic diagnosis in 18 patients out of 19 (94.7%), in one patient, the tissue sample revealed only inflammatory cells and definitive diagnosis could not be reached. There was no significant morbidity or any mortality in the series. CONCLUSION: Abrar and Afzal technique is a reasonably accurate technique of acquiring larger tissue sample in stereotactic brain biopsy without any additional risks. It can be done with little modification of the conventional equipment available with the stereotactic system.

Management dilemma in penetrating head injuries in comatose patients: Scenario in underdeveloped countries.

BACKGROUND: The optimal management of patients with minimal injury to brain has been a matter of controversy and this is especially intensified when the patient has a poor neurological status. This is important in the regions where neurosurgical services are limited and patient turnover is disproportionate to the available resources. We aimed to determine the effectiveness of aggressive management in coma patients after penetrating missile injuries of the brain. METHODS: All the patients of gunshots or blast injuries were included if they had a Glasgow Coma Scale score of less than 8 after initial resuscitation and had no other injury that could explain their poor neurological status. The indication for emergency surgery was evidence of a mass lesion causing a significant mass effect; otherwise, debridement was done in a delayed fashion. The patients who were not operated were those with irreversible shock or having small intracranial pellets with no significant scalp wounds. The patients who had a Glasgow outcome score of 1, 2, or 3 were classified as having an unfavorable outcome (UO) and those with scores 4 and 5 were classified as having a favorable outcome (FO). RESULTS: We operated 13 patients and the rest 13 were managed conservatively. The characteristics of the patients having a favorable outcome were young age (OR = 28, P = 0 .031), normal hemodynamic status (OR = 18, P = 0.08), presence of pupillary reaction (OR = 9.7, P = 0.1), and injury restricted to one hemisphere only (OR = 15, P = 0.07). All of the patients who were in shock after resuscitation died while 25% of the patients with a normal hemodynamic status had a favorable outcome. CONCLUSIONS: In developing countries with limited resources, the patients who are in a comatose condition after sustaining penetrating missile injuries should not be managed aggressively if associated with bihemispheric damage, irreversible shock, or bilateral dilated nonreacting pupils. This is especially important in the event of receiving numerous patients with the same kind of injuries.

Decompressive hemicraniectomy in supra-tentorial malignant infarcts.

BACKGROUND: Decompressive hemicraniectomy not only reduces the intracranial pressure but has been demonstrated to increase survival and decrease the morbidity in patients with supratentorial malignant brain infarcts (STMBI). The aim of this study was to assess the efficacy of surgical decompression to decrease the mortality and morbidity in patients with STMBI refractory to medical therapy and to compare the results with those of the medically managed patients. METHODS: All the 24 consecutive patients with clinical and radiological diagnosis of STMBI, refractory to medical management in 2 years, were included. Option of surgical decompression after explaining the outcome, risk and benefits of the procedure was given to the attendants/relatives of all patients who were fulfilling the inclusion criteria. The patient group, whose attendants/relatives were not willing to undergo surgery, were subjected to the same medical therapy and they were taken as the "control group." RESULTS: Supratentorial malignant infarcts were more common in the age group of 41-60 years. Mean age of presentation was 42.16 ± 16.2 years and the mean GCS on admission was 7.83 ± 2.1. Mortality was 16.7% in the surgically and 25.0% in the medically managed group. Patients operated early (<48 h), age ≤60 years, midline shift <5 mm and size of infarct less than 2/3(rd) of the vascular territory involved showed good prognosis. The functional outcome revealed by modified Rankin Score (mRS) and Glasgow Outcome Score (GOS) was better in surgically managed patients. Results of the Zung Self-Rating Depression Score were better in surgically managed patients at 1 year. Barthal Index in the surgically managed group showed statistically significant results. CONCLUSIONS: Decompressive hemicraniectomy with duroplasty if performed early in STMBI not only decreases the mortality but also increases the functional outcome when compared with patients who were managed conservatively with medical therapy only.

Stray bullet: An accidental killer during riot control.

BACKGROUND: The use of force to control public uprisings, riots, unruly mobs is an important tool in any administrative setup. Law enforcement agencies often resort to aerial firing, which can be responsible for unintended injuries due to stray bullets.This study was designed to study the pattern of stray bullet injuries and to generate awareness about the hazards related to the use of live ammunition during riot control. METHODS: This study was conducted in our unit of the neurosurgery department over a period of 18 months, from June 2008 to December 2010. We enrolled all patients who had head or spine injuries caused by stray bullets from firing during riot control far away from the site of injury. RESULTS: We had two patients with head injury and two with spinal injury sustained because of stray bullets. One of the patients with head injury was operated and the other one was managed conservatively; the latter died on the third day of injury, while the former is surviving with some residual neurological deficit. Amongst the patients with spinal injury, neurological deficits persist till date. None of the patients were aware that they had sustained a bullet injury, and it was only after inquiry that we came to know that the police had resorted to aerial firing for controlling public agitation in nearby areas. CONCLUSION: Aerial firing of live cartridges is generally considered an 'innocuous' method; however, in view of the potential for injury to innocent bystanders, we recommend that the use of live cartridges during aerial firing be banned.

Missile injury to the pediatric brain in conflict zones.

OBJECT: This study was conducted both prospectively and retrospectively at one center over a period of 8 years. The population consisted of all patients with both an age 18 years or younger and a diagnosed penetrating missile injury (PMI) during the study interval. The authors analyzed factors determining outcome and demographic trends in this population, and they compared them with those in the more developed world. METHODS: Fifty-one patients were the victims of armed conflict, although no one was directly a party to any battle. This mechanism of injury is in strong opposition to data in the literature from developed countries, in which most missile injuries are the result of suicide or homicide or are even sports related. Moreover, all previous studies on the pediatric population have considered only injuries from gunshots, but authors of the current study have included injuries from other penetrating missiles as well. RESULTS: On cross tabulation analysis using the chi-square test, the factors shown to correlate with outcome included the Glasgow Coma Scale (GCS) score, pupillary abnormalities, patient age, hemodynamic status, and bihemispheric damage. On multinomial regression analysis, the two strongest predictors of death were GCS score and pupillary abnormalities. The GCS score and hemodynamic status were the strongest predictors of disability. CONCLUSIONS: There was no difference in the prognostic factors for PMI between developing or more developed countries. Glasgow Coma Scale score, pupillary abnormalities, and hemodynamic status were the strongest predictors of outcome. In conflict zones in developing countries the victims were mostly innocent bystanders, whereas in the more developed countries homicides and suicides were the leading etiological factors.

Head injury caused by tear gas cartridge in teenage population.

OBJECTIVES: The aim of this study was to assess the head injury in children caused by an unusual projectile, a tear gas cartridge. The study is the only one on this subject which has been done in a teenage population. METHOD: This was a prospective study conducted over a period of 4 years in which all the patients aged less than or equal to 18 years and who had a head injury due to a tear gas cartridge were included. RESULTS: We had 5 patients in our study group. All the patients were males. Commonest CT scan finding was brain contusion with skull fracture. One of our patients died. One patient continues to be in vegetative state whereas 3 had a good outcome. CONCLUSION: Tear gas cartridge, though considered as one of the benign modalities of controlling agitated crowds, is not really benign. It can cause serious injuries and mortality. The personnel using them might be trained in a better way so that the people do not receive direct hits. In addition some changes in the design of tear gas cartridge can be done to decrease the impact to the skull.