Risk factors and outcome analysis of patients with intraoperative rupture (IOR) of ruptured cerebral aneurysm during microsurgical clipping.

PURPOSE: To analyse baseline characteristics of patients with intraoperative rupture (IOR) or non-IOR who underwent microsurgical clipping for ruptured intracranial aneurysms. Additionally, to asses functional outcome in terms of Glasgow Outcome Scale (GOS) at 6 and 12 months. METHODS: A retrospective analysis of 471 patients who underwent microsurgical clipping for ruptured intracranial aneurysms from 2007 to 2018 in Nepal Mediciti Hospital, Nepal. Patients who underwent surgery for unruptured aneurysm were excluded from the study. The association of the base line characteristic in IOR and non-IOR were analysed. Variables analysed were the Hunt and Hess Scale (HHS) dichotomized as (1-3) and (4-5), Modified Fisher Scale dichotomized as (0-2) and (3-4), type of rupture, use of brain retractor, timing of IOR during surgery, aneurysmal factors (size of the neck, location, lobulation) and time of surgery. Outcome, GOS dichotomized into favourable (4-5) and unfavourable (1-3), assessed at 6 months and 12 months. RESULTS: Out of 471 patients treated for ruptured intracranial aneurysm, IOR occurred in 57 (12.10%) with mean age 49.47 (SD ±12.9), occurred more in smoker than non-smoker (45.6% vs. 18.6%; p=.000) and regular alcohol consumers (36.8% vs. 17.9%; p=.004). Favourable outcome with GOS (4-5) at 6 months was observed among patients with lower HHS (1-3), p=.025 and lower MFS (0-2), p=.04. However, outcome at 12 months was better associated with MFS (p=.013) and aneurysm size (p=.038), with more favourable outcome associated with aneurysm less than 10 mm. CONCLUSIONS: Alcohol consumption and smoking are associated risk factors that may contribute to IOR. HHS and MFS are strong predictors of outcome for IOR patients at 6 months. However, at 12 months, MFS is more predictive of outcome. Aneurysms greater than 10 mm had a strong association with outcome at 12 months than 6 months.

Adaptive profiles of Nellore sheep with reference to farming system and season: physiological, hemato-biochemical, hormonal, oxidative-enzymatic and reproductive standpoint.

This paper outlines the effect of farming systems with reference to season on the body condition score (BCS) and adaptive profile (physiological, hemato-biochemical, hormonal, enzymatic and reproductive parameters) of Nellore sheep. In trial 1, sixty ewe-lambs were allotted to extensive, semi-intensive, and intensive rearing systems (n = 20) and evaluated for BCS at puberty, mating, 2 weeks pre-lambing and 2, 4, 8, and 12 weeks post-lambing. In trial 2, eighteen rams were distributed evenly to three farming systems (n = 6) and evaluated for physiological, hemato-biochemical, hormonal, enzymatic, and reproductive parameters concerning three seasons. Although the scores did not differ among the groups, the Kruskal-Wallis ranks of BCS revealed a higher energy status of intensive ewes at different physiological conditions. The sheep reared under extensive and semi-intensive systems displayed higher temperature, pulse rate and respiratory rate with predominant effects in summer season. Similarly, both systems exhibited higher WBC and lower haemoglobin, PCV, and RBC contents without affecting MVC, MCH, MCHC, and differential leucocyte count. The percent haemoglobin and RBC count were higher in winter compared to summer months, whereas WBC count followed an exactly opposite pattern. The sheep reared in intensive system showed higher glucose, total protein, albumin, cholesterol, T3, T4, calcium, and phosphorus; however, the globulin, creatinine, uric acid, aspartate amino transferase (AST), alanine amino transferase (ALT), superoxide dismutase (SOD), malondialdehyde (MDA), glutathione peroxidase, and catalase levels were elevated in extensive and semi-intensive systems. The dartos muscle extension (DME) and scrotum sweating rate (SSR) were higher for the sheep reared under extensive system, especially during summer season; while the seminal parameters viz., total sperm count, progressive sperm motility, and plasma membrane integrity were lower for extensive and semi-intensive sheep. No interactions were noticed for any of the parameters, except for cortisol, DME, and SSR, which showed significant interactions for rearing system vs. season. Our results showed dynamic adaptive mechanisms of the Nellore sheep in relation to different stressors like grazing for long distances, inadequate nutrition, and heat stress, revealing the heat resilient ability in harsh environmental conditions. Further, the analyzed vector plot showed that the AST, GPx, Cortisol, SOD, Catalase, WBC, PR, T4, total abnormalities, and major abnormalities were the major contributors for adapting during combined stressors.

Farming systems in sheep rearing: Impact on growth and reproductive performance, nutrient digestibility, disease incidence and heat stress indices.

The experiment was conducted with an intent to know the effect of different farming systems on the growth performance, nutrient digestibility coefficients, reproductive traits, disease incidence, heat stress indices, and cost economics of Nellore sheep. The study includes two parallel trials to prevent the influence of age on heat stress indices (panting score and erythrocyte osmotic fragility (EOF)). One hundred and twenty lambs (60 ram-lambs and 60 ewe-lambs) were allotted in a randomized block design under extensive, semi-intensive, and intensive systems for trial I, whereas trial II include eighteen rams assigned to the three respective farming systems in a completely randomised design. Both, season (summer) and grazing practice increased the panting score and EOF. The heat stress indices were positively correlated (P<0.01) with dry-bulb temperature and temperature-humidity index (THI) and inversely correlated (P<0.01) to relative humidity. Allotting the sheep to intensive system increased (P<0.001) weight gain and average daily gain with higher effect in males compared to females. The parameters of asymptotic weight (A), integration constant (B), and maturation rate were higher for intensive males. The male Nellore lambs had higher asymptotic weight and lower maturity rate than females, irrespective of the rearing system. Intensive sheep revealed a higher dry matter intake, digestibility coefficients, feed conversion ratio. The instantaneous bite mass (IBM) was higher for Commelina benghalensis, while instantaneous bite frequency (IBF), instantaneous intake rate (IIR) were higher for Cyanodon dactylon and amaranthus viridis, respectively. The proportion of intakes were highest for Stylo hemata followed by Cynodon dactylon and Tridax procumbens species. No differences were observed for the weight at puberty, oestrus cycle length, oestrus duration, conception percent, gestation period, and lambing percent in three rearing systems; however, the age at puberty was lower (P<0.001) and the birth weight was higher (P<0.001) for sheep reared under intensive farming system. Highest disease incidence was observed in rainy and winter seasons, particularly in sheep reared under extensive system. The capital expenditure was same for the three rearing systems, while the recurring expenditure was higher for Intensive farming system. The gross income and net income were higher for intensive system on account of higher weight gains. However, the higher returns per rupee of expenditure project the extensive farming as an ideal rearing system for small farmers and entrepreneurs with a low initial capital.

Carotid Doppler and lipid profile findings in ischemic stroke patients--a hospital based study.

A prospective study was carried out during 2010 - 2011 in the Department of Radiology & Imaging of Nepal Medical College and Teaching Hospital, Jorpati, Kathmandu and Om Hospital and Research Centre, Chabahil, Kathmandu in which a total of 45 patients with clinically and CT scan diagnosed ischaemic cerebrovascular accident (CVA) underwent carotid Doppler study. During the hospital stay these patients also underwent lipid profile estimation to see for presence or absence of hyperlipidemia. Of these 45 patients, CT scan showed left middle cerebral artery (MCA) infarctions in 12, right MCA infarction in 12, lacunar infarctions in 10, watershed territory infarction in 4, posterior circulation infarction in 1 and venous infarction in 1 patient. Carotid Doppler study showed more than 50% stenosis in 31 patients. Among these 31 patients, 28 had hyperlipidemia where as blood cholesterol and triglyceride values in 3 patients were normal. The present study like several other studies done in the past showed association between carotid stenosis and hyperlipidemia, leading to CVA.

Bilateral, mirror-imaged, postero-inferior cerebellar artery aneurysms: report of a rare case.

A 60-year-old right-handed lady presented with the features of subarachnoid haemorrhage. The CT angiogram showed a pair of very rare bilateral, mirror-imaged distal postero-inferior cerebellar artery aneurysms. Both aneurysms were clipped via the midline posterior fossa craniectomy under general anaesthesia. The literatures is reviewed on the incidence, presentation, management and outcome of bilateral distal posterior-inferior cerebellar artery aneurysms.

Frontal recurrence of medulloblastoma five years after excision and craniospinal irradiation.

Medulloblastomas were originally classified under gliomas of the cerebellum until Bailey and Cushing in 1925 named these tumors as medulloblastoma. At present these tumors are classified under primitive neuroectodermal tumor. Surgical excision followed by craniospinal irradiation is the treatment of choice. A 13-year-old-girl operated for posterior fossa medulloblastoma 5 years ago presented with history of headache and vomiting on and off for 4 days in late August 2008. The MRI showed left frontal tumor which on excision was reported as medulloblastoma. Even after optimal treatment reports of recurrence abound in literature. The most common location is in the posterior fossa, followed by spinal, supratentorial, and uncommonly, systemic metastases. We conclude that medulloblastomas are highly aggressive tumor with high local recurrences if the initial excision is incomplete and that recurrence in the supratentorial area although uncommon is still a possibility. This mandates regular follow up of these children till adulthood to catch early recurrences and metastatic disease.

Traumatic posterior fossa extradural haematoma.

Posterior fossa extradural haematoma is known for the vague signs and symptoms and a notorious course that varies from recovery to sudden death. The incidence of posterior fossa epidural hematomas among intracranial epidural hematomas has been reported from 4% to 7%. Subsequently, PFEDH with low GCS or the haematoma of more than 10 ml were subjected to evacuation. Since the volume of the posterior fossa is limited, patients deteriorate early with the development of obstructive hydrocephalus, which is visible in the CT scan in only thirty percent of cases. A retrospective study of 43 cases was done in this Institute from May 1999 to December 2005. The males (98%) have a clear predominance over female patients (2%). Road traffic accidents accounted for the majority of the cases (80%), fall for the rest (17%) and one case due to a bullhorn injury. Vomiting was the most common symptom accounting for 67% of cases followed by transient loss of consciousness in 48% and headache in 34%. On arrival to the hospital 67% presented with a GCS more than 13, 28% with score of 9-12 and the rest 5% with GCS of less than 8. Out of the total 43 cases of PFEDH surgical evacuation was done in 33(76%) and conservative management in 10 cases (23%). A dichotomised Glasgow outcome score was used to measure the outcome. This was favorable in 27 of the 33 cases operated (81%), and 7 out of the 10 conservatively managed group (70%). Overall favorable outcome was found in 34 cases (79%) with overall mortality of the study being 7%.

Spontaneous intracystic hemorrhage of the arachnoid cyst: a case report and review of literature.

Arachnoid cysts represent benign cysts that occur in the cerebrospinal axis in relation to the arachnoid membrane and do not communicate with the ventricular system. We report a case of a years right handed lady, who presented to the emergency department with the complaints of headache and vomiting for one week CT scan showed extraaxial cystic lesion in the left fronto-parietal region. On the fifth day of admission, patient had sudden onset of severe headache associated with loss of consciousness for about 3-4 minutes with neck rigidity. A CT scan of head was repeated, which showed left fronto-parietal cystic lesion with intracystic bleed and SAH. Intraoperatively, there was intradural cystic lesion containing xanthochromic fluid with normal brain surface and there were no evidence of any vascular malformations. Marsupilization of the cystic lesion was carried out and she improved. The literature regarding arachnoid cyst with spontaneous intracranial haemorrhage is reviewed.

Pattern of adverse drug reactions to anti-epileptic drugs: a cross-sectional one-year survey at a tertiary care hospital.

PURPOSE: To investigate pattern and extent of adverse drug reactions (ADRs) associated with AEDs and to identify safer options for treatment of epilepsy. METHOD: Study was a retrospective, cross-sectional survey. Data from patients with epilepsy at the out-patient and in-patient of Neurology Department was collected in a specially designed proforma. Causality and severity of ADRs was categorized as per WHO guidelines. RESULTS: Among 788 patients with epilepsy, 80 (10.27%) had ADRs. ADRs with AED monotherapy were 9.18% and with polytherapy were 11.56%. ADRs with conventional and newer AED monotherapy was 10.24% and 6.84%, respectively, and were maximum with phenytoin and clobazam (14.28% and 12.5%). ADRs were mild in 4.16%, moderate in 70.83% and severe in 25% patients. Causality was probable in 65.62%, possible in 13.54% and definite in 20.83%. Patients (15/80) were hospitalized due to ADRs. Age and gender distribution showed statistically significant difference in occurrence of ADRs (p < 0.05). Chi-square test for poly versus monotherapy and conventional versus newer AEDs did not show any significant difference. CONCLUSIONS: Study showed maximum ADRs with AED polytherapy with no significant difference in frequency and severity of ADRs between conventional versus newer AEDs. This finding needs further investigation in larger number of patients to identify safer treatment options for epilepsy.

Role of repeat CT scan head in initially inoperable cases of traumatic head injury.

The CT scan has become popular in cases of head injury. In this study 71 cases (M:48; 68.0% and F:23; 32.0%) with traumatic head injury admitted and initially managed conservatively at National Neurosurgical Referral Centre, Bir hospital starting from May 2005 to April 2006. The most common cause of injury was road accidents (43 cases) with motorcycle and bus injuries as the leading causes. Nausea and vomiting were the most common symptom in 41 (57.0%) cases, followed by headache in 31 (43.0%). Contusions were the most common radiological findings in 84.0% followed by extradural haematoma in 8.0% and pneumocephalus in 7.0%. Out of these the most common location for contusion was frontal (16 cases), followed by parietal (12 cases) and then bilateral contusions. The mean volume was 12 ml, 9 ml and 9 ml for frontal, parietal and temporal contusions, respectively. Repeat scan showed increase in volume of contusion in 31 cases (44.0%), no change in 28 cases (40.0%) and decrease in 12 cases (16.0%). The increase was mainly due to edema in 20 cases (64.0%) and due to actual increase in contusion in only 11 cases (35.0%). Only 5 (7.0%) cases needed operative intervention. It is concluded that routine use of repeat scan in mild to moderate head injury has no role unless there is clinical deterioration.

Single burr hole drainage for chronic subdural haematoma.

Chronic subdural haematoma is a common neurosurgical condition and surprisingly surgical treatment ranges from twist drill craniostomy to more radical membranectomy. However, the outcome is generally favourable with appropriate therapy. This retrospective study is aimed at analyzing the result of single burr hole drainage of such haematoma under local anaesthesia over a period of fifteen years. There were a total of 365 patients ranging from 6 months to 89 years with the mean age of 60 years. Recurrence of haematoma was noted in 17 (4.6%) patients and majority of them (65.0%) were managed by aspiration through the previous burr hole. Favorable outcome was noted in 98.6% patients. Those with adverse outcome were in coma preoperatively. This study suggests that single burr hole drainage under local anaesthesia is sufficient in the majority of patients and outcome was favorable even in the elderly provided they presented before lapsing into coma.

Endoscopic treatment of chyluria using povidone Iodine with contrast agent : a preliminary experience

Objective: To evaluate the safety and efficacy of povidone iodine with contrast agent as a sclerosant for the endoscopic treatment of chyluria. Patients and Methods: From December 1999 to October 2003; a total of 22 patients having chyluria were treated. After their baseline evaluation they were subjected to endoscopic instillation therapy. The scleros-ing agent was prepared by using povidone iodine with contrast agent diluted with sterile water in the ratio of 1:1:3. The side with chylous efflux was identified via cysto-scopy. Using a bulb tip ureteric catheter the sclerosing solution was instilled in the pelvicalyceal system. Unilateral instillation was performed in 13 cases; eight on the left and five on the right side. In the remaining nine cases that had bilateral chylous efflux instillation was performed on both sides in the same session. Fluoroscopy was used to see the complete filling of the pelvicalyceal system. The sclerosing solution was kept in the system for five minutes and the ureteric catheter was then withdrawn. Results: All patients were cured from chyluria in the immediate post operative period. Relapse occurred in three patients; but retreatment by instillation therapy resulted in cessation of chyluria also in these cases. The longest follow up was three years; the shortest two months. Fifteen patients were lost to follow up after nine months. None of the cases but the three mentioned previously had relapse during the follow-up period. Conclusion: Povidone iodine is a very safe and efficacious agent for the endoscopic treatment of chyluria by instillation therapy. Using a contrast agent along with it helps to know; under fluoroscopic guidance; the exact amount of sclerosing agent to be instilled to completely fill the pelvicalyceal system. Thus overfilling of the system is avoided and the complications occurring due to pyelointerstitial backflow of the sclerosant are prevented