Efficacy Of Prophylactic Intrawound Application Of Vancomycin Powder In Preventing Surgical Site Infections In Spinal Instrumentation Surgery.

BACKGROUND: Surgical site infection (SSI) is always a matter of utmost concern in cases of spinal instrumentation in low-income countries. This study was conducted to determine the efficacy of local intrawound application of vancomycin powder in reducing postoperative SSI following Thoracolumbar-Sacral spinal instrumentation. METHODS: This randomized controlled trial was done in the Department of Neurosurgery, Ayub Teaching Hospital Abbottabad from 1st July 2019 to 31st December 2021. Seventy-eight patients of either gender with an age range from 15 to 65 years, who were planned for posterior spinal instrumentation surgery (transpedicular screw fixation), were included in the study. Patients were divided into two equal groups, A (Vanco group) and B (control group). In addition to standard systemic prophylaxis, 1 gm of Vancomycin powder was applied over the implant in Group A patients. RESULTS: The mean age of the patients in Group A was 36±16.6 while the mean age of patients in the group was 33.7±15.9 years. A statistically significant reduction of surgical site infection was observed in those who received a prophylactic intra-wound application of vancomycin powder (Vanco group) (5.2%) compared to the control group (20.5%). CONCLUSIONS: Intrawound vancomycin powder administration significantly decreases SSI following spinal instrumentation surgeries. Patients at high risk of infection are highly recommended as a candidate for this technique.

Mortality And Prognostic Factors In Patients Operated For Acute Epidural Hematoma.

Background: Epidural hematoma is one of the most common surgical emergencies encountered in neurosurgery. This study was conducted to determine the mortality and prognostic factors in patients operated for traumatic intracranial epidural hematoma in a resource-constrained setting from a developing country. Methods: This retrospective study was conducted in the Department of Neurosurgery at Ayub Teaching Hospital Abbottabad from 1st January 2019 to 31st Dec 2021. Inclusion and exclusion criteria were created. The medical record of 116 patients admitted and operated on for traumatic extradural hematoma was retrospectively reviewed. Information was recorded using a standardized structured questionnaire. The outcome was measured in terms of the Glasgow coma outcome score. Results: Out of 116 patients, 93 were male and 23 were female.19 (16.4%) patients were in the age range 0-5 years, 42 (36.2%) were in the age range 6-15, 35(31.0%) were in the age range 16-30, 11 (9.5%) were in the age range 31-45 years, 7 (6.0%) were in the age range 46-60 years while only one patient included in this study was above 60 years. Overall mortality was 4.3%. Mortality was higher in females and in those aged less than 5 years (3.4%). 4 out of 16 patients died with GCS less than 8, while none of the patients died when GCS was above 12. Mortality was significantly higher in the presence of associated lesions (4.4% vs. 0%) and anisocoria (2.6% vs.1.7%). Patients who operated within 6 hours of trauma resulted in better outcomes with a mortality rate of 0.0% and functional recovery of 57.8 % while for those who operated after 6 hours, mortality was significantly higher (4.3%) and functional recovery was significantly low (15.5%). Conclusion: Good surgical outcomes can be achieved with early operative intervention if indicated. Female gender, low preoperative GCS score, presence of pupillary dilatation, presence of associated lesions, delayed surgical intervention and age less than 5 years are significant predictors for poor outcomes.

Surgical Treatment Options For Chronic Subdural Haematoma.

Subdural hematoma is an encapsulated collection of blood under the dura matter. This commonly encountered neurosurgical disorder is best managed by surgical evacuation; however, contemporary neurosurgery lacks a consensus regarding surgical technique of choice. Due to high incidence of the condition and associated complications, vast amount of literature is available on the subject; including studies comparing efficacy of various available treatment modalities. Herein, literature on surgical techniques employed for management of Chronic Subdural Hematoma (CSDH) has been reviewed to provide an evidence-based review on best surgical practices. Following conclusions can be made on basis of evidence of various levels provided in the studied literature: (1) Twist-drill craniostomy is a relatively safe technique that can be employed under local anaesthesia, thus can be considered as first line treatment in high risk surgical candidates. (2) Single and double burr-hole craniostomies have shown comparable results. (3) Intraoperative irrigation during burr-hole craniostomy doesn't affect outcome. (4) Drain insertion after hematoma evacuation lowers recurrence risk. (5) Position of drain is not significant but early drain removal is associated with higher recurrence rates. (6) Craniotomy is associated with high morbidity and mortality, hence should be reserved for recurrent and large septate hematoma cases. (7) Head elevation in postoperative period reduces recurrence. (8) Embolization of middle meningeal artery (EMMA): A novel treatment modality, is promising but requires further approval in terms of large sample sized multicenter randomized control trials. In conclusion further research is required on the subject to formulate guidelines regarding management of this common neurosurgical emergency.

Level Of Pre-Tertiary Care Hospital Management Of Traumatic Spinal Cord Injured Patients; Where Do We Stand?

BACKGROUND: Traumatic spinal cord injury is a debilitating condition that may cause long term disabilities with tremendous socioeconomic impact on affected individuals and their families. Secondary injuries can best prevent or minimized by appropriate pre hospital management and proper referral and transfer. This study was conducted to assess the clinical profile of traumatic spinal cord injuries and level of pre-hospital care provided to patients either at the site of injury or at other healthcare facilities. METHODS: This prospective study was conducted in the Department of Neurosurgery Ayub Teaching Hospital Abbottabad, from January 2012 to January 2017. All patients with suspected spinal injury were included in the study. Age, gender, mode of injuries and the pre-tertiary care provided were recorded. RESULTS: Out of 4464 patients with suspected spinal cord injury, 3685 (82.5%) were male, 779 (17.4%) were female. Age ranged from 10-70 years. 1685 (37.8%) were diagnosed as having spinal injury. Cervical spine was the most common affected level 743 (44.09%), followed by thoracic spine 135 (8.01%). 1441 (85.5%) were incomplete while 224(14.5%) were complete spinal cord injuries. Road traffic accident was the most common mechanism of injury 884 (52.4%). Only 4 (0.23%) patients directly received in our unit were properly transported, 66 (3.91%) were brought after proper spinal immobilization, intravenous line was maintained in 584 (34.66%) patients, 410 (24.3%) patients received some fluid resuscitation, parenteral analgesia was given to 441 (26.17%) patients while urinary catheterization was done in 195 (11.75%) patients. Those received from other healthcare facilities only 4 (0.23%) were brought by properly equipped ambulance, intravenous access was maintained in 438 (25.99%),320 (18.99%) received some fluid resuscitation, urinary catheterization was done in 229(13.59%) while proper parenteral analgesia was given to 988 (58.63%) patients. CONCLUSIONS: There is a complete lack of proper transport and referral of trauma patients in our area which reflects almost non-existent emergency medical (rescue) services, deficient health care facilities.

Intradiploic Epidermoid Cyst Of The Skull.

Intradiploic epidermoid cyst is an uncommon, benign, slow growing neoplasm that occurs between two tables of cranial bones and constitute 0.4% of all cranial epidermoid. It usually occurs due to the entrapped ectodermal embyronal remnants within the skull bones or rarely secondary to trauma. Pre-operative diagnosis on the basis of radiologic investigations is difficult. Complete surgically excision is usually required in order to prevent complications like super infection, intracranial rupture with pneumocephalus and rarely malignant degeneration. We are presenting a case of incompletely resected and chronically infected intradiploic epidermoid cyst of right parietal bone operated inadvertently by a general surgeon elsewhere without doing any radiological investigations.

Surgical Outcome Of Intradural Spinal Tumours.

BACKGROUND: This study was conducted to determine the short-term outcome of surgical procedure in patients having spinal intradural tumours. METHODS: This cross-sectional study was conducted from 26 April 2016 to 25 March 2019 on 56 patients after approval from hospitals ethical and research committee. MRI spine were studied in detail for all patients to know about the site, size, shape, extent and nature of the tumour. History, examination, pre-operative MRI findings, post-operative findings were documented in patient's pro forma. Short term as well as long term post-operative results were documented after surgery, during stay at hospital and followup visits till 6 months. RESULTS: In this study, 56 patients with spinal intradural tumours were observed. Male to female ratio was 1.33:1. Age ranged from 5-65 years (32.5±14.6). Paraparesis, hypesthesia, sphincter dysfunction were the presenting symptoms in most of the patients. 47% (21) patients improved according to MRC Grading system 46% (20) patients remained static 7% (3) patients deteriorated. Wound infection was found in 7 (12.5%) patients, followed by Neurological Deficit in 5 (8.9%) cases, Meningitis was found in 2 (3.57%), CSF leak was noted in 4 (7.14%) patients and mortality in 1 (1.7%) of the case. CONCLUSIONS: Surgery of the intradural spinal tumours carry good neurological outcome with acceptable complication rates.

Estimating The Possible Role Of Testing Capacity And Social Distancing In Predicting The Growth Rate Of Daily Covid-19 Cases.

BACKGROUND: The purpose of this study was to estimate the effect of social distancing (days since the imposition of a lock-down) and the number of daily tests conducted per million population on the daily growth rate of COVID-19 cases. METHODS: After excluding the first 30 days since the announcement of an index case in a country, relevant data for the next forty days was collected from four countries: Belgium, Italy, South Korea and United Kingdom. Two online databases: Our World in Data and worldometer were used for the collection of data which included the number of new COVID-19 cases and the number of tests conducted on a given day. The acquired figures were transformed into per million population of the given country. The growth rate of daily COVID-19 cases was derived and was used as the regress and in a multiple linear regression with the number of tests per million population per day and the number of days since a lock-down was imposed as the regressors. RESULTS: It was found that the growth rate of daily COVID-19 cases decreased by .051% when the number of daily tests conducted per million population increased by 1. A .532% decrease in the growth rate of daily COVID-19 cases was observed with each passing day of a lock-down, which essentially represented the most effective form of social distancing. A significant regression was calculated (F (2, 155) = 35.191, p=.014), with an R2 of .054. Neither the daily number of tests conducted per million population nor the number of days of maintaining social distancing (lock-down) was individually significant contributors to the prediction of the growth rate of daily COVID-19 cases (p=.267 and p=.554 respectively). CONCLUSION: An extensive and rapid increase in the daily number of testing capacity and maintaining social distancing can decrease the growth rate of daily COVID-19 cases. Depending on the availability of the required resources, timely implementation of these measures can lead to better outcomes for a given population.

Efficacy Of Phenytoin In Prevention Of Early Posttraumatic Seizures.

BACKGROUND: The use of anti-epileptic drugs for prophylaxis of early post-traumatic seizures after traumatic brain injury has been very promising. The objective of this study was to determine the outcome of phenytoin in prevention of early post-traumatic seizures in moderate to severe traumatic brain injuries and to compare the frequency of seizures in moderate to severe traumatic brain injury, with phenytoin started within 12 hours and after 12 hours of injury. METHODS: This cross-sectional study was conducted at Department of Neurosurgery, Ayub Medical Institute, Abbottabad from April to October, 2015. All the patients with moderate to severe head injury presenting within 48 hours of injury were included in this study in consecutive manner. Patients were started on phenytoin and observed for early post-traumatic seizures. RESULTS: A total of 163 patients were included in this study with a mean age of 24.69±10.186 years. One hundred and twenty-two (74.8%) were males and rest of 41 (25.2%) were females. A total of 26 (16%) patients had early post-traumatic seizures. 9.89% patients in whom phenytoin was started within 12 hours had seizures, while 23.11% patients in whom phenytoin was started after 12 hours of injury had seizures, the difference being statistically significant (p-value .018).. CONCLUSIONS: Frequency of early post-traumatic seizures is high in patients with moderate to severe head injured patients. Anti-epileptics like phenytoin should be started within 12 hours for seizure prophylaxis.

Comparison Of Simultaneous Versus Delayed Ventriculoperitoneal Shunting In Patients Undergoing Meningocoele Repair In Terms Of Infection.

BACKGROUND: Myelomeningocele is a congenital anomaly of Central Nervous System (CNS) leading to serious sequels related to various systems and organs of the affected patient. Hydrocephalus is a common condition associated with myelomeningocele. Hydrocephalus is seen in 11.8% of children with Myelomeningocele (MMC). This study was conducted to compare the simultaneous vs delayed ventriculoperitoneal shunting in children undergoing myelomeningocele in terms of infection. METHODS: This Randomized Control Trial was conducted at department of Neurosurgery, Ayub Medical College, Abbottabad from 7th March to 7th June 2016. In this study a total of 98 patients with MMC and hydrocephalus were randomly divided into two equal groups. In group A simultaneous MMC repair and VP shunting was performed while in group B MMC repair was done in first and VP shunting was done two weeks postoperatively.. RESULTS: In this study mean age in Group A was 1 years with SD±2.77 while mean age in Group B was 1 years with SD±3.12. In Group A (12%) patients had infection and (88%) whereas in Group B (20%) patients had infection and (80%) patients didn't had infection.. CONCLUSIONS: Simultaneous VP shunting was more effective than delayed VP shunting in children undergoing myelomeningocele in terms of infection.

Dural Tears In Patients With Depressed Skull Fractures.

BACKGROUND: The presence of skull fracture in patients sustaining traumatic brain injury is an important risk factor for intracranial lesions. Assessment of integrity of dura in depressed skull fracture is of paramount importance because if dura is torn, lacerated brain matter may be present in the wound which needs proper debridement followed by water tight dural closure to prevent meningitis, cerebral abscess, and pseudomeningocoele formation. The objective of this study was to determine the frequency of dural tear in patients with depressed skull fractures. METHODS: This cross-sectional study was conducted at Department of Neurosurgery Ayub Teaching Hospital Abbottabad. All the patients of either patients above 1 year of age with depressed skull fracture were included in this study in consecutive manner. Patients were operated for skull fractures and per-operatively dura in the region of depressed skull fracture was closely observed for any dural tear. The data were collected on a predesigned pro forma. RESULTS: A total of 83 patients were included in this study out of which 57 (68.7%) were males and 26 (31.3%) were females. The age of the patients ranged from 1-50 (mean 15.71±13.49 years). Most common site of depressed skull fracture was parietal 32 (38.6%), followed by Frontal in 24 (28.9%), 21(25.3%) in temporal region, 5(6.0%) were in occipital region and only 1 (1.2%) in posterior fossa. Dural tear was present in 28 (33.7%) patients and it was absent in 55 (66.3%) of patients. CONCLUSIONS: In depressed skull fractures, there are high chances of associated traumatic dural tears which should be vigilantly managed.

Burr Hole Evacuation of Extradural Hematoma in Mass Trauma. A Life Saving and Time Saving Procedure: Our Experience in the Earthquake of 2005.

AIM: To observe the outcome of burr hole evacuation of extradural hematoma (EDH) in mass head injury. MATERIAL AND METHODS: This study included patients of any age who sustained head injury in the earthquake of October 8, 2005, were diagnosed as EDH on computed tomography (CT) scan and were admitted in the neurosurgery ward over a period of 3 days. All patients were followed by serial CT scans and neurological assessments. RESULTS: A total of 36 patients were included in this study. There were 25 male and 11 female patients and the age range was from 5 years to 50 years. All cases were the victim of the earthquake. All patients underwent surgery for evacuation of EDH through a single burr hole. One patient required craniotomy for EDH due to neurological deterioration on the second postoperative day, and 1 patient died. CONCLUSION: As EDH is potentially fatal lesion, evacuation of EDH through a single burr hole has good outcome with less chances of recurrence and complications in mass head injured patients as seen with earthquakes.

Comparison Of Efficacy Of Phenytoin And Levetiracetam For Prevention Of Early Post Traumatic Seizures.

BACKGROUND: The incidence of early post-traumatic seizures after civilian traumatic brain injury ranges 4-25%. The control of early post-traumatic seizure is mandatory because these acute insults may add secondary damage to the already damaged brain with poor outcome. Prophylactic use of anti-epileptic drugs have been found to be have variable efficacy against early post-traumatic seizures. The objective of this study was to compare the efficacy of Phenytion and Levetiracetam in prevention of early post-traumatic seizures in moderate to severe traumatic brain injury. METHODS: This randomized controlled trial was conducted in department of Neurosurgery, Ayub Medical College, Abbottabad from March, 2012 to March 2013. The patients with moderate to severe head injury were randomly allocated in two groups. Patients in group A were given phenytoin and patients in group B were given Levetiracetam. Patients were followed for one week to detect efficacy of drug in terms of early post traumatic seizures. RESULTS: The 154 patients included in the study were equally divided into two groups. Out of 154 patients 115 (74.7%) were male while 29 (25.3%) were females. Age of patients ranges from 7-48 (24.15±9.56) years. Ninety one (59.1%) patients had moderate head injury while 63 (40.9%) patients had severe head injury. Phenytoin was effective in preventing early post traumatic seizures in 73 (94.8%) patients whereas Levetiracetam effectively controlled seizures in 70 (90.95%) cases (p-value of .348). CONCLUSIONS: There is no statistically significant difference in the efficacy of Phenytoin and Levetiracetam in prophylaxis of early posttraumatic seizures in cases of moderate to severe traumatic brain injury.

Decompressive Craniectomy For Acute Subdural Haematoma With Expansile Duraplasty Versus Dural-Slits.

BACKGROUND: Traumatic subdural hematoma is one of the lethal injuries to brain. Various surgical techniques are used to evacuate the acute subdural hematoma. The hematoma evacuation can either be done by opening of dura by multiple slits or by opening of dura in single large c shape and then doing the expansile duraplasty. Present study aimed to compare both these techniques. METHODS: This randomized control study was conducted in department of neurosurgery, Ayub Medical College, Abbottabad from July 2011 to July 2013. A total of 59 patients were included in this study, which were randomly allocated in two groups (i.e., group A and group B) for decompressive craniectomy. Thirty-one patients were operated by craniectomy with full dural flap opening (Group A), and 28 patients were operated by craniectomy with multidural-slits (Group B). Glasgow Outcome score (GOS) at 6 weeks after the surgery was used to determine the outcome. RESULTS: Mean age of the patients was 33.4±12.8 years. Majority were males. In group A 51.6 % (16) of the patients survived out of which a favourable outcome (GOC 3-5) was observed in 41.9% of the patients, and 9.1% of patients ended up in vegetative state. While in group B 46.4% (13) of the patients survived among which favourable outcome was seen in 39.3% of patients and 7.1% of patients ended up in vegetative state. The difference in outcome measure is insignificant. CONCLUSIONS: There was no statistically significant difference among the two groups as regards the mortality, GOS, frequency of complications and hospital. While the duration of surgery was significantly shorter in patients operated with dural slits.

FREQUENCY OF EXTRADURAL HAEMATOMA IN PATIENTS WITH LINEAR SKULL FRACTURE.

BACKGROUND: Apparently normal looking patients after traumatic brain injury can have serious neurological deterioration, and one of the common causes of such deterioration is extradural haematomas. This study was conducted to determine the frequency of extradural hematoma and common types of trauma leading to it among patients presenting with skull fracture due to head injury. METHODS: This cross-sectional study was conducted in the department of Neurosurgery Ayub Medical College, Abbottabad from June 2011 to June 2012. All patients who were suspected to have Skull fracture on X-ray skull, during the study period, were included in study after informed consent and later on CT-Scan brain was done to see for extradural hematoma. Findings were recorded on a predesigned pro fonna including demographic data, radiological findings and the type of head trauma. RESULTS: Out of 114 patients 85 (74.5%) were males and 29 (225.4%) were females. Age ranged from 2 to 70 years (18.23 +/- 16.5 years). Among these patients the most important cause of head injury was fall from height in 65 (57%), followed by road traffic accidents in 39 (34.2%), and assault in 10 (8.8%) patients. The most common site of fracture was parietal in 49 (43%) of patients, followed by frontal bone in 28 (24.6%) of patients, occipital bone in 24 (21.1%) of patients, and temporal bone in 23 (20.2%) of patients. Frequency of extradural hematoma among linear skull fracture was in 34 (29.8%) patients. Extradural hematoma was most common with parietotemporal linear skull fractures (73.5%). CONCLUSION: Extradural haematoma occurs commonly with linear skull fractures, so patients with linear skull fracture should be properly evaluated with CT brain.

RADIOLOGICAL OUTCOME OF TRANSPEDICULAR SCREWS FIXATION IN THE MANAGEMENT OF THORACOLUMBAR SPINE INJURY.

BACKGROUND: Traumatic fracture of the spine 'is a serious neurosurgical condition that has serious impact on the patient's quality of life. Thoracolumbar junction is the most common site of spinal injuries. The aims of management of thoracolumbar spinal fractures are to restore vertebral column stability, and to obtain spinal canal decompression. This ultimately leads to early mobilization of the patients. This study was conducted to compare preoperative and post-operative vertebral height, kyphotic angle and sagittal index in patients treated with pedicle screws and rods in thoracolumbar spine fractures. METHODS: This cross-sectional study was conducted in the department of Neurosurgery, Hayatabad Medical Complex, Peshawar from 1st. February 2010 to 31st. July 2011. A total 161 patients with unstable thoracolumber spine fracture were included in this study. In these patients fixation was done through transpedicle screws with rods. Anteroposterior and lateral views X-rays of thoracolumbar spine were done pre and post operatively. RESULTS: Out of 161 patients, 109 (67.7%) were males and 52 (32.3%) females. The age of patients ranged from 20 to 70 years (mean 42.2 years) with 71 (44.1%) in the age range of 31-40 years. Preoperative average vertebral height was 9.4194. mm while postoperative average was 19.642 mm. The mean kyphosis was 23.06 degrees preoperatively. Immediately after surgery the average correction of kyphosis was 9.45 degrees. The pre-operative average sagittal index was 19.38 degrees, which was reduced to an average 5.41 degrees post operatively. CONCLUSIONS: Transpedicular fixation for unstable thoraco-lumbar spinal fractures achieves a stable fracture segment with improvement of vertebral height, kyphotic angle and sagittal index. Hence, preventing the secondary spinal deformities.

Lumbar disc herniation in patients with chronic backache.

BACKGROUND: Low back pain with or without lower extremity pain is the most common problem among chronic pain disorders with significant economic, social, and health impact. This study was conducted to determine the frequency of lumbar disc herniation and its different levels, among patients with chronic backache. METHODS: This cross sectional study was conducted in the department of Neurosurgery, Ayub Medical College Abbottabad from January 2011 to January 2013. All the patients presenting with chronic low backache of either gender above the age 14 years were included in the study. Magnetic resonance imaging (MRI) was done in all the patients included in the study to look for lumbar disc herniation. RESULTS: A total of 477 patients with chronic low backache were included in the study out of which 274 (57.4%) were males. Age of the patients ranged from 19 to 75 (39.92 +/- 12.31) years. Out of 477 patients 38 (7.9%) had significant radiological evidence of disc prolapse at lumbar vertebral levels, with 26 (9.5%) males and 12 (5.9%) females. Among these 38 patients with inter-vertebral disc, 20 (52.6%) of patients had disc herniation at L5-S1, 15 (39.5%) at L4-L5, 2 (5.26%) cases at L3-L4 level and only one case (2.6%) had the involvement of L2-L3 level. No cases of L1-L2 disc prolapse were found. CONCLUSION: Patients with chronic backache can have inter-vertebral lumbar disc prolapsed disease. Middle age group are more affected by lumbar disc disease especially at the lower lumbar regions.

Outcome of transcranial repair of traumatic CSF rhinorrhea.

BACKGROUND: Traumatic brain injury represents a significant cause of mortality and permanent disability in the adult population. Posttraumatic CSF rhinorrhea is one of the conditions most strongly associated with severe brain injury. Knowledge on the natural history of the illness and the outcomes of patients with transcranial subfrontal approach for posttraumatic CSF rhinorrhea approach may help the neurosurgeon in the decision-making process. This study was conducted to analyse the outcome of trans-cranial sub-frontal approach for traumatic CSF rhinorrhea, with duroplasty and fibrin glue. METHODS: This study was carried out in the Department of Neurosurgery, Ayub Medical College, Abbottabad from Jan 2007 to Jun 2011. All patients undergoing trans-cranial sub-frontal repair of traumatic CSF fistulas were included. Where possible primary dural repair was performed under hypotensive general anaesthesia and in the cases where it was not possible, graft was used. This was followed by application of fibrin glue at the repaired site. Graft materials used in this study were taken from fascia lata, pericranium, and temporalis fascia. RESULTS: Out of 27 patients 21 were men and 6 were women. Age of the patients ranged from 17 to 56 (34.5 +/- 4.6) years. Main causes of trauma were road traffic accidents (23, 85%), fall from height (3, 11%), and assaults (1, 4%). In 23 (85%) cases no CSF leak was observed in immediate postoperative period as well as during the follow-up visits while in 3 (11%) cases additional lumber punctures were required to augment the repair. One patient failed to respond to surgery and lumbar drainage. CONCLUSION: The CSF rhinorrhea is commonly seen in patients with anterior skull fractures secondary to head injury. Initially conservative trail should be given to the patients, if it fails then on-lay dural technique followed by fibrin glue application through transcranial approach has good outcome with less chances of complications.

Frequency of conservatively managed traumatic acute subdural haematoma changing into chronic subdural haematoma.

BACKGROUND: Traumatic brain injury represents a significant cause of mortality and permanent disability in the adult population. Acute subdural haematoma is one of the conditions most strongly associated with severe brain injury. Knowledge on the natural history of the illness and the outcome of patients conservatively managed may help the neurosurgeon in the decision-making process. METHODS: We prospectively analysed 27 patients with age ranges 15-90 years, in whom a CT scan diagnosis of acute subdural haematoma was made, and in whom craniotomy for evacuation was not initially performed, to the neurosurgery department of Ayub Teaching Hospital Abbottabad (2008-2011). Patients with deranged bleeding profile, anticoagulant therapy, chronic liver disease, any other associated intracranial abnormalities, such as cerebral contusions, as shown on CT, were excluded from this study. All patients were followed by serial CT scans, and a neurological assessment was done. RESULTS: There were 18 male and 9 female patients, Cerebral atrophy was present in over half of the sample. In 22 of our patients, the acute subdural haematoma resolved spontaneously, without evidence of damage to the underlying brain, as shown by CT or neurological findings. Four patients subsequently required burr hole drainage for chronic subdural haematoma. In each of these patients, haematoma thickness was greater than 10 mm. The mean delay between injury and operation in this group was 15-21 days. Among these patients 1 patient required craniotomy for haematoma removal due to neurological deterioration. CONCLUSION: Certain conscious patients with small acute subdural haematomas, without mass effect on CT, may be safely managed conservatively, but due to high risk of these acute subdural haematoma changing into chronic subdural haematoma these patients should be reinvestigated in case of neurological deterioration.

Predisposing factors, clinical presentation and outcome of repeated aspiration in cerebral abscess through a drainage tube in situ.

BACKGROUND: Cerebral abscess is a serious and life threatening complication of several diseases. Aspiration of the abscess cavity versus excision of capsule are still in debate for the capsulated, large, superficially located abscesses especially in patients with poor surgical fitness. The objective of this study was to look for the clinical presentation and outcome of patients with repeated aspiration in cerebral abscess through a drainage tube in situ. METHODS: This prospective study was conducted in Department of Neurosurgery, Ayub Medical College, Abbottabad from Jan 2010 to Jun 2011. Twenty-three patients with age ranges 6-21 years who had large, solitary, capsulated, superficially located abscesses, were included in this study. These patients had poor American Society of Anaesthesiologists (ASA) grading (grade III and IV). After thorough clinical examination and workup, patients were subjected to operative procedure. The procedure included placement of 8 size nasogastric tube in the abscess cavity through a single burr hole. Under strict aseptic conditions, repeated aspiration of pus was done through the drain daily for 2-4 days consecutively at intervals of 24 hours. The demographic data. predisposing factors, clinical presentation, and outcome of patients with repeated aspiration through drain placed in abscess cavity were recorded. Postoperatively, gadolinium enhanced CT-scan was done twice in the first month at the span of two weeks each, later on monthly for next 3 months. The CT-scans were reviewed for recurrence or any other possible intracranial complications. Patients were followed for duration of 3 to 6 months. RESULTS: The predisposing factors found were congenital heart disease in 7 (30.4%) patients, spread of contagious infections like mastoiditis/Chronic suppurative ottitis media in 5 (21.7%) patients, sinusitis in 2 (8.6%) patients, meningitis in 5 (21.7%) patients, septicemia in 3 (13.7%) patients, and penetrating cranial injury in 1 (4.34%) patients. In 16 (69.5%) patients presenting complaints were headache and vomiting, altered sensorium in 8 (34.7%) patients, hemiparesis in 9 (39.1) patients, aphasia in 3 (13.1%) patients, papillodema in 2 (8.7%) patients, and seizures in 1 (4.34%) patients. The abscess resolved in 19 (82%) of patients, recurrence occurred in 2 (8.7%) of patients, and death occurred in 2 (8.7%). CONCLUSION: Cerebral abscess is a life threatening condition requiring aggressive management measures. Aspiration of cerebral abscess with repeated aspiration through a drainage tube is a life saving in patients with poor ASA grade with low recurrence of abscess formation and low mortality.

Transnasal endosocpic repair of cerebrospinal fluid rhinorrhoea.

BACKGROUND: Cerebrospinal fluid (CSF) leaks can arise as a complication of trauma, hydrocephalus, endoscopic sinus surgery or it may occur spontaneously without any identifiable cause. Surgical repair is recommended in patients who do not respond to the conservative management. In recent years transnasal endoscopic approach has become the preferred method for repairing the CSF leaks and better outcomes have been reported as compared to the intracranial approaches that were previously used. Objective of this study was to analyse the outcome of transnasal endoscopic repair of CSF rhinorrhoea. METHODS: This prospective study was conducted in the Department of Neurosurgery, Ayub Medical College, Abbottabad, from March 2007 to March 2010. Twenty-one patients with CSF rhinorrhoea were included in study that were diagnosed on the basis of clinical evaluation, glucose concentration of nasal discharge, computed tomography (CT) and magnetic resonance imaging (MRI). These patients did not respond to conservative management and were operated transnasally using rigid endoscope. Patients were followed up for a mean duration of 9 months and the outcome was analysed. RESULTS: The patients included in the study ranged in the age group of 12-55 years. Among the patients 13 (57%) were female and 8 (38%) were males. The cause of CSF rhinorrhoea was traumatic in 16 (76.19%), Idiopathic or spontaneous in 4 (19.04%) and 1 (4.7%) case was related to endoscopic surgery for pituitary macroedenoma. In 10 (47.6.8%) patients the site of leak was cribriform plate, 5 (23.8%) had from sphenoid, 4 (19.04%) from frontal sinus and in 2 (9.5%) Ethmoid was affected. Primary surgery was successful in 17 (80.95%) of cases. In 2 (9.5%) cases re-exploration had to be performed. In 1 patient re-exploration had to be done for the third time. Overall success rate was 95%. One patient presented with CSF leak and meningitis 1 month after surgery and unfortunately died. CONCLUSION: Transnasal endoscopic repair of CSF rhinorrhoea is highly successful, safe and less traumatic.