Intra thecal baclofen pump as an ad hoc measure for a case of severe tardive dystonia refractory to multiple lesioning.

Tardive dystonia is an infrequent ailment in patient reliant with chronic antipsychotic medication. The front-line envoy in the treatment of this illness is set into motion with oral agents including baclofen, benzodiazepines, and other antispasmodics. Regardless of an extensive therapy, the patients are not able to control of their spasticity/ dystonia. The authors reported a case of severe tardive dystonia treated with baclofen therapy in a patient frigid to medical therapy and multiple lesioning. Case Report: A 31-year-old female, diagnosed as a case of depressive illness and being managed with neuroleptic medications, who went onto develop tardive dystonia progressively worsening over a 4-year duration. After a comprehensive and meticulous evaluation of her neurological and psychological stratum, globus pallidus interna lesioning was reputed as the best course of action. As intended, staged lesioning was executed bilaterally with a trivial resolution eventually succumbing into recurrence, compelling a repeat lesioning. It was inaptly discouraging to see her crippled with the plight. Determined, not to give upon her, a way out with a baclofen therapy was proposed. A test dose with a 100 mcg of baclofen with an increment up to 150 mcg over a 3-day period demonstrated a promising prospect. On that account, the insertion of the baclofen pump was performed with an outstanding aftermath in her neurological endeavor. Clinical Discussion: Tardive dystonia is believed to be caused by striatal dopamine receptor super-sensitivity persuaded by the dopamine-antagonizing action of antipsychotic drugs. The first line of treatment being oral agents including oral baclofen, benzodiazepines, and antispasmodics. If the patient suffers from an early-onset primary generalized dystonia, then treatment with deep brain stimulation of the globus pallidus interna is the approved and preferred treatment approach. Recurrence of the symptoms despite of multiple lesioning can be overcome by intrathecal baclofen pump infusion as stated by many research. It is not uncommon to face complications in such a procedure, but the benefits outreach the risk, which makes it a choice of treatment. Conclusion: The use of a continuous intrathecal baclofen pump for cases with tardive dystonia refractory to conventional therapy, it has been approved as one of the safest and capable procedures.

Venture of a Tertiary Care Neurosurgical Center in Course of COVID-19 Lockdown without RT-PCR.

"I will not permit considerations of age, disease or disability, creed, ethnic origin, gender, nationality, political affiliation, race, sexual orientation, social standing or any other factor to intervene between my duty and my patient." Obliged by the aforementioned oath, no medical practitioner shall sit in a moral judgment on any patient but will treat their illness to the best of their ability whatever the circumstances. A clear concord was yet to be authorized after the World Health Organization (WHO) declared the global pandemic of severe acute respiratory syndrome coronavirus 2infection. As a diagnostic modality, WHO recommended real-time reverse transcription-polymerase chain reaction (RT-PCR) as a reliable test; however, its availability in a deprived nation like ours became a major restraining factor. Despite an asset of having high specificity, RT-PCR for coronavirus disease 2019has its own liability of having low sensitivity. Henceforth, as time passed by, the validity of the rapid diagnostic tests was put into question. In later months, a few centers around our periphery started conducting RT-PCR, but the time taken to obtain the result was long-drawn-out process and the patient who needed urgent neurosurgical intervention at Annapurna Neurological Institute and Allied Sciences had to wait. We would like to share our expedition through peaks and valleys of managing 215 patients during the vicious circle of lockdown and global pandemic.

Early internal capsule infarction following globus pallidus internus lesioning for cervical dystonia.

INTRODUCTION AND IMPORTANCE: Ischemia associated with lesioning for the treatment of cervical dystonia is a very rare phenomenon. We reported a case of early internal capsule infarction following GPi lesioning for cervical dystonia. CASE PRESENTATION: A 56-year-old man with one year history of progressive onset of cervical dystonia which was unresponsive to medical therapy. He was planned for bilateral globus pallidus internus pallidotomy. After completion of the procedure on one side and the successful completion of stimulation and test lesion on another side, the patient suddenly developed dysarthria and one sided weakness. Post-operative magnetic resonance imaging revealed acute infarction in the posterior end of the internal capsule. The patient was managed conservatively and underwent physiotherapy and rehabilitation care. He recovered gradually with modified ranking scale 3 on discharge. CLINICAL DISCUSSION: Globus pallidus internus lesioning or ablation is one of the surgical treatment for dystonia and movement disorder. Though considered as a safe technique, various risk are associated with the procedure. Ischemia is one of the associated risk but is a very rare phenomenon. Though the patient did not have any signs of pre-operative ischemia, the occlusion of one of the perforators to internal capsule during ablation may be the cause of intra-operative ischemia. CONCLUSION: Ischemia associated with lesioning in the treatment of cervical dystonia is a very rare phenomenon. Though, ischemia related with radiofrequency ablation is very rare and sporadic, one has to be very cautious during GPi pallidotomy to prevent occlusion of perforators to internal capsule.

Customized Cost-Effective Polymethyl-Methacrylate Cranioplasty Implant Using Three-Dimensional Printer.

There is no doubt that many synthetic materials used in cranioplasty have given good result regarding patient's calvarial shape. However, the use of these materials is costly to the patient and requires complex intraoperative process. There has been a long history regarding the use of acrylic bone cement called as polymethyl-methacrylate (PMMA) as an implant due to its desirable properties. Here, we present three cases of simple, cost effective manually sculpted calvarial defect using three-dimensional (3D) printer. Sharing the achievement and challenges, we want to focus that the 3D customized implant of PMMA can be used as bone substitute.

Study of Anterior Commissure-Posterior Commissure Distance among Nepalese Cohort.

INTRODUCTION: The main aim of this study is to determine the anterior commissure-posterior commissure (AC-PC) distance in Nepalese cohort and has comparison of intercommissural distance of Nepalese cohort with some other races. MATERIALS AND METHODS: The 47 patients, with mean age of 50 years, included in the study had undergone DBS or lesioning (Pallidotomy). Data were collected through the magnetic resonance imaging under DBS protocol and the manipulation, marking of AC and PC was done in Inomed Planning Software (IPS). RESULTS: The data revealed average AC-PC distance of Nepalese cohort to be 24.86 ± 2.08 mm, ranging from 16 mm to 30 mm. The study among 29 males and 18 females illustrated male to have longer AC-PC as compared to female (25.38 mm male and 24.02 mm female). The results also confirmed age related changes in AC-PC distance which was linearly increasing with the age. CONCLUSION: Comparison of data from other studies revealed Nepalese cohort to have almost similar AC-PC distance with Asian population, while that was longer in Caucasian and shorter in Hispanic Population.