Safety of Diagnostic Cerebral and Spinal Digital Subtraction Angiography in a Developing Country: A Single-Center Experience.

BACKGROUND: Digital subtraction angiography (DSA) remains the gold standard imaging modality for cerebrovascular disorders. In contrast to developed countries, the safety of the procedure is not extensively reported from the developing countries. Herein, we present a retrospective analysis of the basic technique, indications, and outcomes in 286 patients undergoing diagnostic cerebral and spinal angiography in a developing country, Pakistan. METHODS: A retrospective review of patient demographics, procedural technique and complication rates of 286 consecutive patients undergoing the diagnostic cerebral/spinal angiography procedure at one institution from May 2013 to December 2015 was performed. Neurological, systemic, or local complications occurring within and after 24 h of the procedure were recorded. RESULTS: Mean age reported for all patients was 49.7 years. Of all the 286 cases, 175 were male (61.2%) and the rest female (111, 38.8%). Cerebral DSA was performed in 279 cases (97.6%), with 7 cases of spinal DSA (2.4%). Subarachnoid hemorrhage was the most common indication for DSA accounting for 88 cases (30.8%), closely followed by stroke (26.6%) and arteriosclerotic vascular disease (23.1%). No intra- or post-procedural neurological complications of any severity were seen in any of the 286 cases. One case of asymptomatic aortic dissection was reported (0.3%) in the entire cohort of patient population. CONCLUSION: Diagnostic cerebral/spinal digital subtraction angiography was found to be safe in Pakistan, with complication rates at par with and comparable to those reported in the developed world.

Outcome in Chronic Subdural Hematoma After Subdural vs. Subgaleal Drain.

OBJECTIVE: To compare the outcome after surgery for chronic subdural hematoma when the drain is placed in subdural space or subgaleal space. STUDY DESIGN: Quasi experimental study. PLACE AND DURATION OF STUDY: Combined Military Hospital, Lahore, from July 2015 to June 2016. METHODOLOGY: Patients with chronic subdural hematoma of both genders and age, ranging between 55 to 85 years, were included. Patients on antiplatelet/anticoagulant therapy and acute on chronic subdural hematoma were excluded. Patients were divided in two equal groups each depending on whether drain was placed in subgaleal space (Group 1), and subdual space (Group 2), (n=31 patients each). Patients were positioned flat in bed after surgery. Clinical and radiological parameters and clinical outcome were compared between the two groups. Statistical test with significance of p <0.05 was utilized using Statistical Package of Social Sciences (SPSS version 17). RESULTS: Median age of the 62 patients was 72 ±12.5 years. Headache was the most common symptom reported in both groups, (n=47,75.8%) patients. Median thickness of hematoma was 15 ±6.5 mm. Patients with subdural drain placement had more complications such as pneumocephalus 11 (35.4%) vs. 6 (19.3%), and intracerebral hemorrhage 4 (12.9%) vs. 2 (6.4%). Clinical outcome was good in both groups 27 (87%) in Group 1 and 28 (90%) in Group 2. CONCLUSION: Patients of both groups had good outcome after surgery. Complications like pneumocephalus and intracerebral hemorrhage were more common in subdural location of drain, though not reaching statistically significance level to favor one technique over another.

Cutaneous myiasis of scalp in a young girl related to Musca domestica.

Cutaneous myiasis is a parasitic disease secondary to the presence of the larvae of certain insects, particularly diptera, in the skin of man or vertebrates [1]. Human myiasis is a rare clinical condition, but more frequently seen in tropical and subtropical areas. Hot humid climate with inadequate sanitary conditions favor the development of this condition. Dermatitis, psychiatric illnesses, leprosy, and diabetes are some contributory factors [2]. Treatment of myiasis, once diagnosed, is simple and rapid recovery is anticipated.

Non-communicating extradural arachnoid cyst of dorsal spine.

Extradural arachnoid cyst in the spine is an uncommon cause of spinal cord compression in the paediatric population. Most reported cysts have communication with the intrathecal subarachnoid space through a small defect in the dura. The reported child had spinal cord compression caused by a large spinal extradural arachnoid cyst in dorsal spine that did not communicate with the intradural subarachnoid space. Surgical excision of cyst was done with recovery of neurological deficit postoperatively.

Effect of head positioning on outcome after burr hole craniostomy for chronic subdural haematoma.

OBJECTIVE: To determine the effect of position of the patient's head after burr hole craniostomy on the outcome of chronic subdural haematoma, in terms of haematoma efflux, hospital stay and recurrence rate. STUDY DESIGN: Quasi experimental. PLACE AND DURATION OF STUDY: Combined Military Hospital, Rawalpindi, from February 2007 to February 2008. METHODOLOGY: Sixty patients were divided in two equal groups of 30 patients each. Group A patients were kept flat after the burr hole craniostomy and group B patients were kept with head end of bed elevated by 30 degrees. The results were statistically analysed through software SPSS 14. RESULTS: The mean age was 59.98 +/- 13.7 years. There was predominance of males (M:F=3.2:1). The location of haematoma was frontoparietal in majority (72%), right sided in 31 (51.6%), left sided in 20 (30%) and bilateral in 9 (15%) patients. Average daily output was 152 ml in group A and 142 ml in group B. Haematoma efflux was found to be sufficient in 26 (86.6%) patients of group A and 27 (90%) of group B. Wound infection occurred in 2 patients of group A and 1 in group B. Seizures occurred in 2 patients of group A and 3 of group B. Although, there was longer hospital stay for group A vs. group B (p=0.002), recurrence rate was insignificant amongst the two groups as 10% vs. 13% (p=0.688). CONCLUSION: Assuming a 30 degrees head up position soon after operation in cases of chronic subdural haematoma does not significantly affect the outcome and recurrence.

Outcome of primary bone fragment replacement in compound depressed skull fractures.

OBJECTIVE: To assess the outcome in terms of infectious complications after primary bone fragment replacement in compound depressed skull fractures, regardless of the degree of wound contamination. DESIGN: Case series. PLACE AND DURATION OF STUDY: Combined Military Hospital, Rawalpindi, from August 2005 to October 2006. PATIENTS AND METHODS: Patients of all ages and both genders with compound depressed skull fractures irrespective of the degree of wound contamination were selected. Patients with already infected skull wounds were excluded. Bone fragments were replaced in all cases. Main outcome variables were age, associated CT scan findings, type of fracture, location of fracture, wound type, admission to operation time, interval and infectious complications after surgery. RESULTS: Of the 51 cases, the wounds were classified as clean in only 9 patients and the rest had variable degrees of contamination. Thirty five patients were operated within 24 hours, 13 were debrided and bone fragments replaced within 24-72 hours and 3 patients were treated after 72 hours. Thirty five patients were earthquake victims. The average age of the patients was 28.6 years. Three patients developed wound infection and osteomyelitis. One patient had free-floating bone fragments due to the development of hydrocephalus with no evidence of infection. CONCLUSION: Bone fragment removal in compound depressed skull fractures, regardless of the degree of wound contamination, is not obligatory and primary bone fragment replacement is a suitable alternative, which also avoids a second cranioplasty.