ABSTRACT

The 36th Annual Conference
PAKISTAN SOCIETY OF NEUROSURGEONS

ABSTRACTS

AUDIT OF 450 CASES OF INTRACRANIAL ANEURYSMS CLIPPING

WAQAS BASHIR, MUHAMMAD ANWAR CH., FOUZIA SAJJAD, AMIR AZIZ, IJAZ WAAD, FAIQ SHEIKH.

Department of Neurosurgery Punjab Institute of Neurosciences Hospital, Lahore (PINS).

ABSTRACT

Objective: Aneurysm’s clipping is the cornerstone of vascular neurosurgery. The incidence of intra-cranial aneurysm is high and complications happen due to late presentation. The standard neurosurgical clipping can not only diminishes the risk of rupture but also allows for permissive hypertension. A centre like PINS is helping newly neurosurgeons to experience and master in art of clipping. This study will also help to do comparison against recognized standards of surgical practice that will support improvement in the quality of patient care.

Materials and Methods: This study was conducted in Neurosurgery department of Punjab Institute of Neurosciences Hospital Lahore from 2015 to 2021 (6 years) with a follow up period of 12 months. Total 450 aneurysms clipped that were classified according to location like anterior communicating 49.11%, middle cerebral artery 30.44%, posterior communicating artery 8%, distal anterior cerebral artery 6%, internal carotid artery 4.66% and multiple aneurysms 1.77%. Variables like gender, age, WFNS grade at presentation, time of surgery and use of temporary clipping were measured.

Results: 45 out of 450 patients had postoperative ischemia on CT scan brain plain due to vasospasm. 30 patients had re-exploration surgeries like decompressive craniectomy or ventriculoperitoneal shunt. Mortality was 6.66% in post-operative period.

Conclusions: Overall survival and outcome after clipping was satisfactory. Only 30 out of 450 patients died due to late presentation and surgical complications. The learning curve of neurosurgeons was high with improved surgical expertise in fissure dissection and application of clip.

Key words: Clipping, Permissive hypertension, WFNS grade, Decompressive craniectomy, Ventriculoperitoneal shunt, Temporary clipping, PINS (Punjab Institute Of Neurosciences).

Burnout and Ways to Reduce It among Postgraduate Residents of Neurosurgery

1 Muhammad Usman, 2 Shahzad Hussain Waqar

1 Department of Neurosurgery, PAF Hospital, Fazaia Medical College, Islamabad

2 Department of Surgery, Pakistan Institute of Medical Sciences, Islamabad

ABSTRACT: Introduction: The objective of the study was to know the rate of burnout and to explore the potential means to reduce burnout among neurosurgery residents.

Methods: This mixed-method explanatory sequential study was conducted at the Neurosurgery department of Lady Reading Hospital, Peshawar from July to September 2021. In the first phase of the study, burnout was assessed in postgraduate residents of Neurosurgery and its relationship with different demographic factors (quantitative). In the second phase, focus group discussion with the residents were conducted to explore the ways to reduce burnout in residents (qualitative).

Results: Burnout was found in 17 (73.9%) residents. The relationship between different demographic factors with burnout was not statistically significant. The results of the FGDs showed that the reasons behind burnout are; more workload, decrease interaction with the seniors, extra burden on trainees, conflicts with patient’s attendants, increased entries in the HMS system, wrong referrals from the periphery, decrease security of doctors in high-risk areas and lack of ownership by the seniors. The postgraduate residents suggested different ways to reduce burnout; including proper security of residents and all the staff, appreciation of the performance, peripheries should be developed and functional, SOPs for every part of the training should be advised, and proper training of the ancillary staff.

Conclusion: The majority of the neurosurgery residents were burnout and there is no statistically significant difference between different demographic factors related to burnout. This study also provided preliminary ways to reduce burnout amongneurosurgery residents.

Keywords: Burnout, Neurosurgery, Residency, Demographic Factors.

___________________________________________________________________

Corresponding Author:

Dr. Muhammad Usman, Associate Professor, Department of Neurosurgery, PAF Hospital, Fazaia Medical College, Islamabad – Pakistan.

Email: drusman387@yahoo.com

FREQUENCY OF SEIZURES AFTER HEAD INJURY TRAUMA

OBJECTIVE: Aim of the study is to know the frequency of post traumatic fits.

Dr.Azhar PGR Neurosurgery Dept PUHMS W Nawabshah.

STUDY DESIGN: Descriptive study.

PLACE OF STUDY: Department of Neurosurgery, peoples University of Medial & Health Sciences, Nawabshah.

DURATION: One year from 1st July 2022 to 31st December 2022.

MATERIAL & METHODS: there were total 79 patients included in this study who were admitted through emergency in Neuro-trauma unit of this department with head injury. Head injuries were due to RTA (road traffic accident), falls sports or assaults as evident on CT Scan Brain after ruling our other life- threatening poly-trauma injuries. Glasgow coma scale (GCS) was used to categorize severity of head injuries into mild (GCS 14-15), moderate (GCS 9-12) & severe (GCS 3-8).

RESULTS: There were 79 patients with head injury presented in Neuro trauma unit of this department included in this study with multiple types of head injuries. In which immediate seizure, <24 h (11 Patient 14%), early seizure<7 days (23 Patient 29%), late seizure > 7 days (45 patient 57%). The post traumatic seizure developed in 9% with mild , 19% with moderate & 72% 0f patient of severe traumatic brain injury. Radiologically 26(33%) patient with Brain contusion, 19(24%) patient with ASDH, 17(21%) with DAI, 6(8%) with Cerebral edema, 6(8%) with EDH, 3(4%) with skull fracture and 2(2%) with normal ct scan brain plain developed Post traumatic seizures. The incidence of seizures in contusions is highest of 33% of head injured patient.

CONCLUSION: seizures are common complication of moderate to severe head injury, which may arise over many years. ICH & contusion shows more risk of developing seizures along with smaller age group patients. A treatment strategy is needed to be framed for management & prevention of post traumatic seizures.

Traumatic Brain Injuries in PMC hospital Nawabshah

Dr.Azhar PGR Neurosurgery Dept PUHMS W Nawabshah.

Objective: The objective is to know the incidence of traumatic Brain Injury at PMC hospital Nawabshah.

Study Design: Descriptive study. Place of study: Department of Neurosurgery, Peoples University of Medical & Health Sciences, Nawabshah. Duration: From June 2022 to June 2023. Material and Methods: Total 3889 patients From June 2022 to June 2023, presented at our Emergency Department of PMC Hospital Nawabshah with head injury were included in this study. Patients underwent detailed clinical and radiological evaluation as per trauma protocol. Results: Total 3889 patients presented in emergency department from which 1726 patient admitted in Neurosurgery department of PMC Hospital Nawabshah (including 436 (24%) patients with Brain Contusion, 326 (18%) patients with EDH, 266 (14%) patients with SAH, 189 patients (10%) with Skull Bone fracture, 164 (9%) patients with normal CT Scan, 136 (7%) patients with DAI, 123 (6%) patients with ASDH, 86 (4%) patients with ICH. Those patient included 424 patients operated in emergency due to traumatic brain injury (including 179 (42%) of EDH, 78(18%) of Brain, 69(16%) of ASDH, Contusion, 56 (13%) patients of Fracture. The most commonly affected age group was 21 to 30 years.

Conclusion: RTA and falls are the predominant causes of traumatic brain injury in our area. Although this can be minimized by wearing proper helmets, its use is limited. Keywords: Traumatic brain injury (TBI), PMC.

Intramedullary spinal disorder in unusual Neurosurgical disorder

Prof. Dr. Mumtaz Ali, Dr. Tariq Jamal

Ali institute of Neurosciences, Irfan general hospital Peshawar.

Abstract:

Objectives: To assess the presentation and clinical outcome in terms of neurological status of a unique case of Cervical intramedullary spinal lipoma.

Materials and methods: The case study was carried out at Neurosurgery Department, Ali institute of Neurosciences, Irfan general hospital, Peshawar. Intramedullary spinal lipoma is extremely rare at Craniovertebral junction which has rarely been reported at national or international level. We operated a young male of 25 years with history of progressive weakness in all limbs for two years without any pain. He was also having poor sphincter control and was unable to walk. On examination there was spastic myelopathy with power 3/5 in all myotomal groups of muscles, with hypoesthesia below neck without sensory distribution. Jaw jerk was unremarkable. MRI features were suggestive of intradural hyperintense lesion on T1 and T2weighted images extending from foramen magnum to C3. The presumed radiological diagnosis made was cervical meningioma with some variant features. Per operative findings were consistent with cervical lipoma excised microscopically.

Results: After the surgery, the patient remained in stable condition with improvement in neurological status. He was sent home on 4^th post-operative day

Conclusion: The preoperative and postoperative findings along with literature review will be discussed in this case presentation.

Supra palmar approach of carpel tunnel syndrome

Prof. Dr. Mumtaz Ali, Dr. Irfan Ali.

Ali institute of Neurosciences, Irfan general hospital Peshawar.

Abstract:

Objectives: To assess the results of Carpel tunnel release via minimal invasive Supra palmer approach and compare with the conventional open technique.

Materials and methods: This is a prospective study carried out from June 2021 to July 2023 at Neurosurgery department, Ali institute of Neurosciences, Irfan general hospital, Peshawar. It includes 128 cases managed surgically via Supra palmer approach. Carpel tunnel syndrome is one of the common entrapment neuropathy which are managed not only the neurosurgeons but also by orthopedic surgeons, plastic surgeons and sometimes even by general surgeons. The exact etiology is unknown but certain factors commonly involved like diabetes mellitus, hormonal dysfunction syndromes (acromegaly, hypothyroidism or rheumatoid arthritis) and pregnancy. In majority of cases the cause is unknown but disease is common in those more prone to work particularly at wrist joint. Clinical examination and nerve conduction studies are helpful in establishing diagnosis. Laboratory investigations can be performed to dig out the underlying cause. In case of moderate and severe cases, surgical treatment gives excellent results while for the less severe cases, life style modification and rehabilitation services are effective in relieving the symptoms. Surgical decompression of median nerve by conventional open method or minimally invasive endoscopic procedures are carried out commonly around the globe. We have started a supra palmar minimally invasive decompression technique two years back which is more safe, less time consuming, easy to understand and to practice with minimal complications.

Results: In these two years we have operated 128 cases with excellent results considering the appearance of scar, relief of symptoms and accurate decompression from space of parona to kaplan line.

Endoscopic excision of 3rd ventricle colloid cyst; a safe procedure

Dr.Afaq Ahmad Qarnain Khalil, Prof. Dr.Mumtaz Ali.

Ali institute of Neurosciences, Irfan general hospital Peshawar.

Objectives: To assess the clinical outcomes and complications of endoscopic excision of 3rd ventricle Colloid cyst.

Materials and methods: Colloid cysts are benign epithelial lined cysts, which is typically found in the 3rd ventricle. Although usually asymptomatic, they rarely present with acute hydrocephalus. This retrospective case series is carried out from Jan 2020 to March 2023 in Ali Institute of Neurosciences, Irfan General Hospital, Peshawar. Total number of 21 patients were operated in this time period, with 16 male patients and 5 females. Only patients presenting with symptoms of hydrocephalus due to colloid cysts in the 3rd ventricle were included in this study. Mostly, patients presented with headache, blurring of vision, and vomiting without any localizing signs. On examination, there was papilledema in 84 percent of the patients. We performed CT brain and/or MRI brain with contrast, showing Hyper intense lesion on T1WI and Isointense to Hyper intense on T2WI with heterogeneous or peripheral rim contrast enhancement. Mostly blocking bilateral foramen of Monro leading to obstructive hydrocephalus. We performed endoscopic colloid cyst excision with or without endoscopic third ventriculostomy or septum pellucitodomy. The colloid cyst was removed totally in 17 patients (81%), In the remaining cases it was tightly adherent to the roof of the 3^rd ventricle, which limited the radicality of the procedure.

Results: Post operatively, the patients were followed at immediate post-op interval, after one month, 6 months, and 1-year interval. Most of the patients improved with relief of symptoms and return to normal activity including work within 4 to 6 weeks with none to minimal post-operative complications. Some developed complications like seizures, aseptic meningitis, or later on hydrocephalus that needed VP shunting and two patients had recurrence of the colloid cyst.

Conclusion: Endoscopic excision of Colloid cyst from the 3^rd ventricle is a safe procedure with good clinical outcomes and fewer complications.

Foot drop; a management dilemma for Neurosurgeons

Prof. Dr. Mumtaz Ali, Dr. Aafaq Ahmad Qarnain Khalil

Ali institute of Neurosciences, Irfan general hospital Peshawar.

Abstract:

Objectives: To study the management of foot drop recent experience of clover tap technique in 6 patients.

Materials and methods: This is a prospective study carried out at Neurosurgery Department, Ali institute of Neurosciences, Irfan general hospital, Peshawar. Foot drop has different causes that includes Idiopathic foot drop, post discectomy foot drop or post sciatic nerve injury foot drop. Overall foot drop is a common complication seen in neurosurgical practice. Mostly patients are sent for rehabilitation after primary surgical procedures. As rehabilitation takes longer time, which gives physical and psychological dissatisfaction to the patient. Rehab includes vigorous physiotherapy along with the use of AFO. We decided to start the tendon transfer procedure (clover tap) about 8 months back in our neurosurgery department. Those patients who were having foot drop with preserved inversion and plantar flexion.

Conclusion: The clinical data along with outcome and steps of surgical technique will be discussed in presentation.

Efficacy of Multifractional Treatment in Children with Brain Stem Glioma based on a Clinical Assessment

Aurangzeb Abbasi, Abdul Sattar M. Hashim, Kashif Ahmed Pakistan Gamma knife Radiosurgery Centre. Neurospinal and Cancer Care Hospital.

ABSTRACT:Objective: Brainstem gliomas present significant challenges due to their poor prognosis and limited feasibility for surgical resection. This study aims to investigate the clinical efficacy of gamma knife radiosurgery as a potential treatment modality for brainstem gliomas. Through a comprehensive analysis of patient data and outcomes, we aim to provide valuable insights into the effectiveness of this non-invasive approach for managing this aggressive form of brain tumor.

Methods: From 2010 to 2020, our hospital treated a total of 48 patients diagnosed with brainstem gliomas using gamma knife radiosurgery as part of their treatment plan. The patients who underwent this procedure were consecutively treated and had a median age of 10.5 years, ranging from 4.2 to 17.9 years. The median prescribed total dose administered during three to five fractions was 23 Gy, with a range of 16 to 30 Gy. Additionally, the median biological effective dose was 42.63 Gy, ranging from 25.58 to 48 Gy and the median follow-up period was 58 months. The results showed promising progression-free survival rates, with 91.7%, 82.8%, and 70.8% at 1, 3, and 5 years, respectively. Results: After observing the patients with brainstem gliomas for a median follow-up of 53.5months, it was found that the median overall survival was 19 months. The primary goals for assessing survival rates at 1 and 2 years were achieved, with overall survival rates of 87.5% and 52.4%, respectively. Among the patients, four individuals experienced radiation complications. Specifically, three patients had grade 2 radiation-related toxicity, and one patient experienced grade 3 toxicity.

Conclusion: The use of Gamma knife radiosurgery multiple fractions in the treatment of brainstem gliomas has proven to be highly effective. The precise targeting capability of the Gamma knife allows for focused radiation on the affected area, minimizing damage to surrounding healthy tissue. The use of multiple fractions of Gamma knife radiation has demonstrated better tumor control and improved patient outcomes. Overall, Gamma knife radiosurgery in treating brainstem gliomas is a significant advancement in neuro-oncology.However, it's important to note that treatment outcomes may vary depending on individual cases.

Keywords: brainstem gliomas, gamma knife, radiosurgery, pediatric population.

Aurangzeb Abbasi, Abdul Sattar M. Hashim, Kashif Ahmed Pakistan Gamma knife Radiosurgery Centre

Neurospinal and Cancer Care Hospital.

Keywords: brainstem gliomas, gamma knife, radiosurgery, pediatric population.

Aurangzeb Abbasi, Abdul Sattar M. Hashim, Kashif Ahmed Pakistan Gamma knife Radiosurgery Centre. Neurospinal and Cancer Care Hospital.

Keywords: brainstem gliomas, gamma knife, radiosurgery, pediatric population.

Department of Neurosurgery Hayatabad Medical Complex/ Medical Teaching Institute, Peshawar.

SOHAIL AMIR

ASSISTATNT PROFESSOR NEUROSURGERY HAYATABAD MEDICAL COMPLEX, PESHAWAR, (e-mail: dr.sohailamir@gmail.com / Contact: +923325723653)

ABSTRACT:

Objective:To determine if endoscopic third ventriculostomy (ETV) is effective in the treatment of obstructive hydrocephalus.Study Design: Prospective study. Setting: Department of Neurosurgery, Hayatabad Medical Complex, Peshawar. Period: February 2018 to March 2021.

Material & Methods: EightyFive patients underwent endoscopic third ventriculostomy (ETV) for obstructive hydrocephalus all patients with obstructive hydrocephalus of any gender and age more than 6 months were included in the study. Patients age less than 6 months, recurrent cases and those refuse to opt for ETV were excluded from our study. The information regarding patient demographic, etiology, complications of procedure were documented in proforma.

Data was analyzed using SPSS version 20.0 and presented in form of tables.

Results: In the current study out of 85 patients, 48(56.4%) were male and 37(43.5%) were females with male to female ratio=1.23. ETV had successful outcome in 66(77.6%) patients. The sign and symptoms of raised intracranial pressure resolved in all patients after ETV. Overall complication rate in our study was 22(25.8%). The commonest complication was inadequate ventriculostomy in 10(11.7%), per operative significant bleeding in 4(4.7%) of patient, seizure in 3(3.5%) of patients, CSF leak and intraventricular hemorrhage in 2(2.35%) respectively.

Conclusion: ETV is minimally invasive, safe, effective mode of treatment for obstructive hydrocephalus. Success rate is higher in children below 5 years of age. The overall success rate varies from 70-80% in various studies. Key words: Complication, Endoscopic Third Ventriculostomy, Obstructive Hydrocephalus.

Single and Multisession Gamma knife Radiosurgery for Intracranial Lesions: Analysis of initial 1000 cases treated at DUHS, Ojha Campus Karachi

Muhammad Abid Saleem, Atif Mansha, Amjad Shahani, Sohail Hussain, Shahzaib Naeem.

Gamma Knife Stereotactic Radiosurgery Center, Dow University of Health Sciences, Ojha Campus, Karachi.

Objective: To report the demographics, disease and treatment related characteristics of Initial 1000 patients treated in single and multi-sessions at Gamma Knife Radiosurgery Centre, DUHS.

Methods: We conducted a retrospective review of all the treated patients. Descriptive statistics were performed for socio-demographic information. Mean and standard deviation was computed for continuous variables and proportions were generated for categorical variables. All the data was analyzed using statistical package for social sciences version 23.

Results: A total number of 1150 patients were treated between August 2021 to August 2023, at Gamma Knife Radiosurgery Center, DUHS, Karachi, over this period. Overall, patient outcomes have been excellent. Treated lesions include benign tumors such as meningioma (147), pituitary adenoma (85), and acoustic neuroma (103), craniopharyngioma (20), malignant tumors such as brain metastases (31), and high- grade gliomas (188), and conditions such as Trigeminal Neuralgia( 69), and Arteriovenous Malformations of the brain(62). Our own experience has been very favorable with less than 2% of patients suffering significant complications. The few patients with radiation edema/necrosis have responded well to steroid therapy. We have observed no cases of radiation induced tumors, and hair loss is uncommon. Loss of cognitive function, which sometimes occurs with whole brain radiation, is not typically seen with gamma knife radiosurgery.

Conclusion: Gamma knife radiosurgery is a noninvasive technology useful in the management of multiple types of cerebral lesions. It is safe, and, in many conditions, highly efficacious.

Correspondence:

Muhammad Abid Saleem

Consultant Neurosurgeon and HOD.

Gamma Knife Radiosurgery Center,

Dow University Of Health Sciences, Ojha Campus, Karachi.

m_abidsaleem@hotmail.com

03323414304.

Challenges in the management of Pediatric Brain Tumors in LMICs – What’s the way forward?

Dr. Mahjabeen Memon, Prof. Riaz A. Raja.

Liaquat University of Medical and Health Sciences (LUMHS), Jamshoro/Hyderabad

ABSTRACT:

INTRODUCTION: Pediatric brain tumors are the most common type of solid childhood cancer.

The management relies on multi-disciplinary approach which is challenging in low and middle-

income countries (LMICs) where health system is not well established.

METHODS: A retrospective review of all pediatric brain tumors presented to our department during August 2020-2022 was done. We recorded variables like age, sex, clinical presentation, surgical details, morbidity and mortality, histopathology, lost to follow-up and recurrence rates.

RESULTS: Total 67 cases were registered. There were 32 males and 35 females ranging between age 3months-18 years. Out of 65 brain tumors, 44 were supratentorial and 21 were infratentorial. 18 (27%) were posterior fossa tumors, 17 (25%) Suprasellar, 11(16%) Gliomas, 5 (7%) Intraventricular (CPCs), 3 (5%) soft tissue tumors, 3 (5%) Arachnoid cysts, whereas PNET, Pineal tumors, Spine tumors, CPA lesions and meningiomas were 2 each. We operated 47 cases and referred the rest of them to institutes with better facilities. The unavailability of pediatric ICU, lost to follow-up, lack of dedicated pediatric neuro-oncology unit, increased disease burden and poor infra-structure were few of the many causes of hindrance in the management.

CONCLUSION: Burden of pediatric brain tumors is very high in LMICs but the management is challenging due to lack of multi-disciplinary approach and proper infrastructure. Measures such as regular tumor board meetings, adequate training and manpower, dedicated neuro-oncology unit, proper tumor registry and referral are few steps that can be taken to improve the quality of care.

KEYWORDS: Pediatric Brain Tumors, LMICs, multi-disciplinary approach

Technical Report of Free Hand Pedicle Screw Placement using Kim’s Entry Point for Lumbosacral Spine

Nadia Banaras, Saleem Mosakhail, Mustafa Wardac, Abid Hussain.

Objective: Different methods for lumbosacral pedicle screw insertion have been advocated; however, each technique has its cons and pros. Limited resources for C-arm and navigation in our locality enforced us to use our surgical skills to minimize the need for such advanced modalities. This study reported Kim's entry point of lumbosacral pedicle screws with free hand technique and the accuracy of this technique.

Methodology: We retrospectively reviewed the 118 cases with free hand placed lumbosacral pedicle screw placement. The diagnosis included 68 cases with degenerative spine, 45 cases with trauma, 5 cases with metastatic disease. A total of 708 lumbo-sacral pedicle screws were placed, and the entry points of lumbosacral pedicle screws were the junction of proximal edge of transverse process and lamina. Incidence and extent of cortical breach by misplaced pedicle screw was determined by review of intra-operative and post-operative radiographs and/or computed tomography.

Results: Among the total 708 lumbo- sacral free hand placed pedicle screws,32 screws (4.5%) in 15 patients (12.7%) were repositioned screws with suspected screw malposition during operation, and 11 screws (1.5%) in 6 patients (5.08%) were identified as moderate to severe breaching the pedicle after post-operative imaging studies. Among the patient with malposition screws, 3 patients showed nerve irritation sign of the lesion, and 2 cases were symptom improved after nerve block and conservative management, and 1 case was removed the screw after the failure of the treatment.

Conclusion: Free hand pedicle screw placement based on external landmark with the junction of proximal edge of transverse process and lamina showed acceptable safety and accuracy and avoidance of radiation exposure.

Keywords: Lumbar spine, Pedicle screw placement, Free hand technique, Surgical technique.

OUTOME OF ENDOSCOPIC TUBULAR DISCECTOMY COMPARED TO CONVENTIONAL DISCECTOMY FOR THE TREATMENT OF LUMBAR DISC HERNIATION: EARLY INSTITUTIONAL EXPERIENCE

Dr. Aurangzeb, Prof.Dr.Riaz Ahmed Raja, Dr.Suhail A Aghani, Dr.Sanaullah Pathan, Dr.Peer Asad.

Dept. of Neurosurgery, Liaquat University of Medical & health sciences, Jamshoro

ABSTRACT: Background: Lumbosacral radiculopathy is frequently the result of lumbar disc Herniation (LDH). Commonly open and minimally invasive discectomy procedures are viable options for its treatment.

Methods: A two-year Randomized Controlled Trial took place at the Neurosurgery ward of Liaquat University Hospital in Hyderabad. The study included a total of 67 patients who were selected using consecutive sampling technique. These patients were then randomly assigned to two groups: Group 1 consisted of 33 patients who underwent endoscopic discectomy, and Group 2 comprised 34 patients who underwent open discectomy. To evaluate the outcomes, a questionnaire was utilized, which included pre- and post-operative measurements using the Visual Analogue Scale (VAS), Oswestry Disability Index Score, and Modified MacNab criteria. The follow up was done after a one-month period.

Results: The most frequently encountered disc level was L4-L5 (n=41), and the prevailing type of disc was Posterolateral (n=57). Comparing endoscopic and open groups, there was a significant enhancement in post-operative SLR (Straight Leg Raise) in the endoscopic group compared to the open group (p=0.001). Post-surgery, 95.56% (31 out of 33 patients) in the endoscopic group had ODI (Oswestry Disability Index) scores ranging from 0 to 40%, while 76.74.5% (26 out of 34 patients) in the open group fell within the same ODI range (p=0.000). Additionally, 90.2% (30 out of 33 patients) in the endoscopic group experienced noteworthy improvement in VAS (Visual Analog Scale) scores (ranging from 1 to 3), in contrast to 67.5% (23 out of 34 patients) in the open group (p=0.035). Furthermore, 87.80% (29 out of 33 patients) in the endoscopic group reported excellent outcomes, whereas 82.23% (28 out of 34 patients) in the open discectomy group had excellent outcomes (p-value 0.001).

Conclusion: The study at our hospital suggests that endoscopic tubular discectomy outperforms open discectomy in various aspects. These benefits include smaller incisions, shorter hospital stays, higher patient satisfaction, reduced blood loss, and notable improvements in post-operative VAS (Visual Analog Scale) and ODI (Oswestry Disability Index) scores.

Keywords: Lumbar Disc Herniation, Endoscopic Tubular Discectomy, Open Discectomy.

THE FATE OF SEIZURES IN PATIENTS HARBORING SUPRATENTORIAL BRAIN TUMORS AND UNDERGOING SURGICAL RESECTION

Sana Akbar Qazi*, Rabail Akbar Qazi, Tanweer Ahmed, Anita Ghazal, Ali Afzal, Iram Bokhari

Abstract: Background: Seizures are one of the most common presentations of the brain tumors and perhaps also the most alarming ones. Achieving seizure freedom in patients with brain tumors is dependent on many factors, many of which remain under appreciated and poorly understood.

Objective: To assess the factors that determines seizure freedom post-operatively in patients possessing supratentorial brain tumors.

Methods: A prospective study was carried out in 435 patients with history of seizures and diagnosed with Cerebral Supratentorial tumors. The outcome was assessed post- operatively in terms of seizure freedom against factors like age, gender, location and characteristics of the tumor, pre-operative control of seizures with anti-epileptics, extent of resection, seizure seismology, and their duration.

Results: Complete resection of the tumor was most likely to achieve seizure control postoperatively (304 patients; 72%) when compared with partial tumor resection (226 patients, 52%). Pre-operative control of the seizures with anti-epileptics (196 patients; 45%) and shorter time duration suffering from epilepsy (less than 1 year in 265 patients; 61%) were also associated with higher seizure-free survival. Generalized seizure seismology seemed to fare better post-operatively as observed in 282 patients (65%) as well as temporal lobe location (270 patients; 62%) and extra-axial tumors (78%). Overall, 330 patients achieved seizure freedom (76%), whereas, 105 patients (24%) still suffered from epilepsy, post-operatively.

Conclusion: Gross-total resection of the tumor, pre-operative control of seizure on medications, temporal or extra-axial location and a generalized seizure seismology were more likely to be associated with adequate seizure freedom, post-operatively.

Keywords: Seizures, Anti-epileptics, Seismology.

ANALYSIS OF RELATIONSHIP BETWEEN SUBAXIAL PEDICLE SCREW MALPOSITION AND VERTEBRAL ARTERY INJURY ON CADAVER

Ozcan SONMEZ ^1,2, *, Yahya GUVENC ^1,2, Buket GEDIK ³ , Kadir KOLCAK ³

¹Department of Neurosurgery, Marmara University School of Medicine, Istanbul,

Turkey

² Instute of Neurological Sciences, Marmara University, Istanbul, Turkey ³ Department of Pathology, Marmara University School of Medicine, Istanbul, Turkey

Presenter: Ozcan SONMEZ, MD. Fevzi Cakmak mah. Muhsin Yazicioglu cad. No: 10 Pendik/Istanbul/Turkey, (ozcansonmez@ymail.com)

Introduction: Aim of study is test the safety margin hypothesis for prevent vertebral artery injury which one of the most serious consequences of screw malpostion, investigating sensitivity of existing classifications of cervical screw malposition in detecting vertebral artery damage, as well as determining threshold value at which screw malposition causes vertebral artery injury.

Methods: Anatomical measurements were taken using preoperative CT scans on five human cadavers. Transpedicular screws were placed to create lateral pedicle violation. Postoperative measurements were taken using CT scans and vertebral arteries were dissected to macroscopically and histopathologically assess damage.

Results: Our findings revealed correlation between safety margin, consisting of combined distance of vertebral artery from the lateral and medial walls, and area occupied by screws within the foramen for causing vertebral artery damage. The classifications described in literature did’nt show a relationship with vertebral artery damage. Critical threshold for causing vertebral artery damage is exceeding safety margin.

Conclusion: Our study has confirmed presence and effectiveness of safety margin. It has demonstrated the lack of significant relationship between classifications of cervical screw malposition in the literature and vertebral artery damage. New classification was made with the cadaveric results from study. Our study contributes to literature as the first experimental study highlighting the importance of considering the safety margin and position of the vertebral artery, increased vertebral artery injury risk at dominant side because of smaller safety margin and importance of preoperative examination of vertebral artery on both sides although the artery is pushed laterally during screw malposition.

Transforaminal discectomy under local anaesthesia; my experience

Dr. M Farooq Sherzada 1 , Prof. Dr. Mumtaz Ali 2 , Dr. Ali ShahJehan 3

Abstract:

Introduction: Transforaminal discectomy is presently the least invasive surgical procedure for Lumber disc herniation (LDH). PTED is usually performed under two anaesthesia methods i.e. Local and General. It is said that local anaesthesia has more benefits and less complications.

Objective: this study aims to analyse the effects of local anaesthesia performed in Transforaminal lumber discectomy in patients with LDH under the supervision of one neurosurgeon at Afridi medical complex, Peshawar.

Methods and materials: This research was done on patients with failed conservative treatment. Patient’s demographic data i.e. gender and age were analysed through descriptive statistics. Standard tools like VAS and ODI scores were used pre-operatively, intra-operatively and postoperatively after 12 months to evaluate the effects of local anaesthesia. Pain was analysed during operation which was usually caused by exiting nerve root or insertion of dilators/working sheath. Moderate pain was recorded by 70% of the population while 30% population had severe pain according to VAS scoring system.

Results: ODI and VAS showed significant improvement after the PTED done under LA and there were less complication rates. Patients undergone PTED had less post-operative surgical complications and more positive outcomes. Only pain during the surgery was one of the negative factors. The most common complication was nerve root injury.

Conclusion: patient underwent PTED under Local Anaesthesia is a safe procedure with less complication rates.

Keywords: Full Endoscopic spine surgery, transforaminal discectomy, local anaesthesia minimally invasive spine surgery, lumber disc herniation, intraoperative pain, discectomy.

1 Endoscopic and neuro spine surgeon

Doctorkhan79@gmail.com (0333-9263600)

2 Neuro spine Surgeon

NS.Mumtazali@gmail.com

3 Neuro spine surgeon

Alijehan4@gmail.com (0333-9697741).

Comparison of Outcomes and Post-Operative Complications in Minimally Invasive Discectomy and Open Discectomy for the Management of Lumbar Disc Herniation.

Dr.Tahreem Fatima1,, Dr.Umar Nadeem2, Prof.Dr.Shahzad Shams, Dr.Muhammad Umar Hassan, Dr.Ayesha Farooq, Dr.Aleeha Batool, Dr.Zubia Afzal, Dr.Wiem Mansour, Dr.Zeineb Hammoud, Dr.Solay Farhat, Dr.Azam Niaz, Dr.Abrar Ullah Khan, Dr.Rizwan Iftikhar, Dr.Muhammad Umar Ikram, Dr.Tajamul Saeed, Dr. Ahtsham Ishaq, Dr.Ahsan Iqbal, Dr.Muhammad Naeem, Dr.Haris Masood 1, 2, Department of Neurosurgery, Mayo Hospital, Lahore.Corresponding author: ReemFatima528@yahoo.com

Abstract:

INTRODUCTION: Lumbar Disc Herniation (LDH) is one of the most common degenerative diseases worldwide with an estimated prevalence of 2-3%. The first line of treatment for LDH is conservative measures. However, upon their failure, surgical treatment for LDH is warranted for which multiple approaches and methods have been developed including open discectomy and minimally invasive discectomy. This study aims to bridge this gap in data and compare the two approaches in terms of postoperative variables including complication, neurological improvement, and pain relief.

METHODS: A prospective cohort multi-center study was conducted in 3 public sector hospitals present in Lahore over a period of 6 months (from January 2022 to June 2022). The participants of the study mainly comprised patients aged 21 to 60 years old, with low back pain who were non-responsive to medical management or who were progressively worsening despite medical management with one or more radiological evidence of lumbar disc herniation. Two methods of surgical intervention were usedand stratified random sampling was used to select the population and then, patients underwent either Open Discectomy or Minimally Invasive Discectomy. Patients were followed up for up to 6 months postoperatively. Data was collected using a well-structured handwritten Performa by the physician and informed consent was taken from participants. Data Analysis was performed using SPSS version 26.

RESULTS: The total number of participants included in the study was 30. The mean age of the study population was 36.2 ± 10.1 years and 70% of the participants were male. The most common mode of injury was due to lifting heavy objects (34%). At the presentation, the pain was the predominating symptom but other than four patients, almost all the patients showed a neurologic deficit which was predominantly unilateral (73.3%) and right-sided (36.67%). The median pre-operative pain in patients was 6 (IQ Range 1) on the visual analogue scale of pain and the median strength/power of the muscles of the lower limb was 4 (IQ Range 1). CT-Scan Findings were absent in the majority of the cases whereas MRI-Findings were predominantly present in all the cases. The Chi-Square test showed that there was a significant association between the type of surgical procedure (open versus minimally invasive) and postoperative neurological improvement (p=0.002), the incidence of postoperative CSF discharge from the wound (p<0.001), the incidence of postoperative surgical site infection (p=0.001), and the incidence of postoperative discitis (p<0.001). Furthermore, the independent sample t-test showed a significant association between the type of surgical procedure and duration of hospital stay (p<0.001) whereas the Mann-Whitney U test depicted a significant association between the type of surgical procedure and postoperative pain (p<0.001). Linear regression analysis showed that there was only a significant relationship between the surgical intervention and the post-operative pain of the patient (p=0.001) when all the other predictors including age, gender, mode of injury, limb suffering from a neurologic deficit (Unilateral versus Bilateral versus None), power/strength of the affected limb were accounted for.

CONCLUSION: The study suggests that lumbar disc herniation is common in middle age males and commonly caused due to lifting heavy weights. Pain and neurologic deficits are predominant presenting complaints and radiological findings are more prominent in Magnetic Resonance Imaging as compared to Computed Tomography The comparison of surgical interventions in our study suggests that minimally invasive discectomy causes better pain relief and improvement in neurological deficit, and fewer complications as compared to open discectomy.

KEYWORDS: Minimally invasive, Discectomy, Disc Herniation.

Head Injury and underage motorcyclists: An ever-increasing menace in a lower- middle-income country

Authors:

Mohammad Ashraf 1, 2 (corresponding/presenting author)
Usman Ahmad Kamboh 2
Syed Shahzad Hussain 2
Muhammad Asif Raza 2
Mehreen Mehboob 2
Mohammad Zubai 2
Manzoor Ahmad 2
Naveed Ashraf 2

Affiliations:

Wolfson School of Medicine, University of Glasgow, Scotland, United Kingdom 1 2. Department of Neurosurgery, Allama Iqbal Medical College, Jinnah Hospital, Lahore, Pakistan 2

Abstract:

Background and Objectives: Poor societal attitudes and inadequate law enforcement have greatly contributed to the increase in underage motorcycle driving in Pakistan. This study reports the burden of traumatic brain injury (TBI), clinical characteristics/outcomes, and reason for driving in underage motorcyclists.

Materials and Methods: A prospective study was conducted throughout 2021. Demographics, mechanism of injury, helmet use, number of passengers, clinical outcomes, reason for driving and parental awareness/consent status, referral pathway, and transport duration were documented.

Results: Of a total of 1052 motorcyclists with TBI, 112 were underage drivers. The mean age was 14.7 years (range, 10-17 years); 98.2% were male and 17% wore protective helmets. The most common reason for driving was recreational, followed by for domestic chores. In 66 patients, there was parental awareness and 30 of these patients had active parental consent. These patients reported domestic chores as the reason for their journey, whereas recreational purposes were a more prevalent reason in patients without parental awareness/consent (P < 0.001). Most patients were brought by provincial ambulance service (response time 12.8 minutes). Some patients came from peripheral hospitals (26.8%) and private hospitals (14.3%) that lacked neurosurgical cover, and these were associated with severer baseline injuries (P < 0.001). The average stay was 6.5 days, and 75.9% of patients were discharged with a good Glasgow Outcome Scale score.

Conclusion: Most underage patients with TBI resulting from motorcycle driving are adolescent boys who do not use helmets. Trauma prevention systems and involvement of multiple stakeholders are needed to reduce underage driving. Efficient referral systems must transport patients to appropriate neurosurgical cover, which is lacking outside major cities.

Keywords: (1) Head Injury; (2) Motorbike; (3) Underage driving.

Effect of the COVID-19 Pandemic on the Trends of Traumatic Brain Injury in Pakistan: A Retrospective Review of Patient Charts.

Salaar Ahmed 1 , Ammar Anwer 2 , Muhammad Abdullah 1 , Mohammad Ashraf 3 , Javaria

Siddiq 4 , Naveed Ahmed Khan 5 , Hira Khan 1 , Javed Iqbal 4

1: Medical College, Aga Khan University, Karachi

2: Department of Neurosurgery, University College of Medicine, and Dentistry, The University of Lahore, Lahore

3: Wolfson School of Medicine, University of Glasgow, Scotland

4: Department of Neurosurgery, Mayo Hospital Lahore

5: Department of Plastic Surgery, University College of Medicine, and Dentistry, The University of Lahore, Lahore.

Presenting Author: Salaar Ahmed

Medical College, Aga Khan University, Karachi

salaar.ahmed@scholar.aku.edu

Male Hostels, Aga Khan University, Stadium Road, Karachi, 74800

Introduction: Traumatic brain injury (TBI) is one of the leading causes of injury-related deaths, making it a public health concern of extreme importance. In a developing country such as Pakistan, TBIs are significantly underreported, with the treatment frequently being delayed and inadequate, especially in rural healthcare setups all across the country. The COVID-19 pandemic brought consequential changes to the healthcare system with the priority shifting towards COVID-19 patients, resulting in considerable changes to the workflow and management of TBI.

Methods: A retrospective study was conducted at a tertiary care center in a metropolitan city in Pakistan. Patient charts were reviewed from January to August 2020, and data was extracted including demographics, clinical presentation, management, and outcomes for cases of TBI.

Results: The total number of patients is 2126, male 78% and female 21.4%. The mean age of the patients was 28.85. The state of admissions at the hospital is at 99.7% for EME admissions and 0.282% for OPD admissions. Participants presented with loss of consciousness (70.7%), nosebleeds, (53.2%), vomiting (69.0%), and seizures (11.5%). The majority (51.1%) were related to road traffic accidents, followed by falls (20.7%), and assaults (4%). While 1202 (58.5%) of these were managed conservatively, others underwent surgical treatment in the form of craniotomy (28.0%), Burr holes (3.20%), and fracture elevation and repair (10.5%). A decrease in the number of reported TBI cases was observed with the lockdown implementation in Pakistan.

Conclusion: The transportation sector in Pakistan was severely affected by the COVID-19 pandemic, leading to a decline in RTIs and TBIs. Stringent mobility constraints and changes in societal and cultural norms have contributed to this reduction.

Keywords: Traumatic Brain Injury (TBI), COVID-19, Road Traffic Accidents (RTAs).

Woven Endobridge (WEB) embolization of bifurcation aneurysm; Transition from WEB-able aneurysm to WEB-suitable and finally WEB-perfect one, based on personal experiences of 10 consecutive cases

Won Huh Consultant neurosurgeon, Department of Neurosurgery

Sheikh Khalifa Specialty Hospital (SKSH), Ras Al Khaimah, UAE
Mobile. +971 (0)54 377 6002
Email: Won.Huh@sksh.ae, kahnemon@gmail.com

Abstract:

Endovascular treatment of bifurcation aneurysms such as terminal internal carotid artery, anterior communicating artery, and middle cerebral artery often require complex techniques such as stent-assisted coiling and flow diverter deployment. The endosaccular flow disruptor device, Woven Endobridge (WEB), was developed in 2011, and considerable evidence from clinical studies has been established. Herein I present the initial experiences of WEB for treating bifurcation aneurysms in a single center and show the applicability of this device.

Surgical Outcomes in Patients with Posterior Fossa Space Occupying Lesions: A Tertiary Care Center Experience.

Urooba Mateen. Department Of Neurosurgery, SMBB Trauma centre, Civil Hospital Karachi

Abstract

Background: Posterior fossa space occupying lesions have been a cause of significant morbidity and mortality, often exposing the patients to grave morbid conditions such as hydrocephalus and cranial nerve deficits leading to loss of gag and cough. These tumors mainly affect children and young adults. The prognosis after tumor resection, adjuvant chemo and radiotherapy and conservative management is generally not good. To our knowledge not much work has been done in this regard in our region, to elaborate the outcomes of the neoplastic lesions of posterior fossa after surgery.

Objectives: We aim to evaluate the pre and post op status of the patients diagnosed with posterior fossa tumor and observe surgical outcomes.

Methods: We performed retrospective clinical cohort study of 64 patients operated for posterior fossa tumor resection at Neurosurgery Department, SMBBIT Trauma Center at Karachi from January 2018 to June 2023. These included patients who underwent open surgical excision with or without CSF diversion procedures, mainyly ventriculoperitoneal shunt (VP Shunt). Pre-op and post-op status of the patients observed from the hospital record.

Results: Among the 64 observed patients, average age was 20.09 ± 13.4years (ranged 2-49 years). 26 (40.6%) were male patients and 38 (59.4%) were females. Commonly involved sub- regions in posterior fossa were cerebellum (39.1% ) and 4 th ventricle (25%). Medulloblastoma had highest number cases that presented with symptoms of raised ICP at initial presentation. Pilocytic astrocytoma had mostly excellent and good surgical outcome; in 18 cases (28%) and highest rate of survival.

Conclusions: With the better knowledge of prognosis and surgical outcomes for tumor type and specific site, neurosurgeons will be able to decide better approach for patient. In our study we compared our clinical findings with rest of the available clinical data. Pilocytic astrocytoma has been associated with good prognosis and survival rate and comparatively lower rate of post-op complications.

Keywords: posterior fossa, surgical outcome, tumors, space occupying lesions, brain tumors.

Intracranial Meningioma; assessment of tumor size and clinical features on first presentation

Dr Haris Hamid, Neurosurgery Department JPMC, Karachi.

Abstract

Objective: To assses the tumor size of intracranial meningioma on first presentation and and their clinical features.

Methods: A prospective review of patients undergoing meningioma resection at the Neurosurgery department, Jinnah Postgraduate Medical Center, Karachi was performed. The clinical records and imaging studies of 43 patients with symptomatic intracranial meningiomas were analysed. The patients were followed up with imaging studies, tumour size, location, first sypmtom, clinical signs and outcomes were evaluated. Patients with incomplete information, spinal meningioma, multiple meningioma were excluded.

Results: There were 30 (72%) women and 13 (28%) men with a mean age of 55.5 years ( median 54.50; standard deviation 13.86; range 21-84 years). The duration of study period was 8 months. Skull base and covexity meningioma were found to amongst the highest frequency of 21 patients (29%) and 20 patients (28%) respectively. The average tumor size was recorded to be greater than 20mm and less than 40mm in 25 patients (60%). The most common symptom was headache(19 patients 44%) followed by seizure (5 patients 13%). The first clinical feature found out on the highest size (59mm) was found to be higher mental function impairment.

Conclusion: Statically significant association was found between tumor size and location, types of first symptom, physical examination, surgical outcomes. Large tumor size is associated with a greater risk of higher mental function impairment along with headache and seizure being the most common clinical feature on first presentation.

THE SURGICAL OUTCOME OF INTRAMEDULLARY SPINAL CORD TUMORS

Dr Haris Hamid, Neurosurgery Department JPMC, Karachi.

Abstract

Objective: To assess the outcome of the intramedullary spinal cord tumor.

Methodology: This is a Prospective study conducted on 42 patients, in the Department of Neurosurgery of a tertiary care hospital in Karachi. In our study, a consecutive series of 42 patients were referred to our institution and underwent surgical treatment. There were 27 male and 15 female patients. Mean age was 43.3 years. Functional outcome was analyzed depending on histological features, age, tumor localization and the extension of involved spinal segments. The mean follow-up period was 6 weeks. Operative removal of the IMSCT was performed under standard surgical conditions.

Results: The most frequently involved localization was the cervical and cervicothoracic region 23 patients (55%) followed by the thoracic region 13 patients (32%) and the medullar conus 6 patients (13%). The most frequent IMSCTs were neuroepithelial tumours in 27 (65%) patients including 15 (55%) patients with ependymomas, 10(37%) astrocytoma’s, and 2(8%) lesions without further histological classification. Non- neuroepithelial tumours included 15(35%) patients, 5(34%) patients with metastases, 8 (53%) hemangioblastomas, one(7%) dermoidal cyst and one(7%) enterogenetic cyst. Complete tumor removal was achieved in 34 cases (83.3%) and subtotal resection in four cases (8.3%). In four cases (8.3%) a biopsy was performed only. The overall postoperative neurological state was improved in 38 (90%) patients and worsened in 4 (10%) patients.

Conclusions: The strongest predicting factor of functional outcome was the preoperative neurological condition beyond the histological differentiation of the IMSCT. Although there was no outcome difference with respect to the age and tumor extension, thoracically located IMSCTs proved to harbor an increased risk of postoperative surgical morbidity.

PREDICTING POST RESECTION PERSISTENT HYDROCEPHALUS IN PEDIATRIC PATIENTS WITH POSTERIOR FOSSA TUMORS USING CANADIAN PREOPERATIVE PREDICTION RULE FOR HYDROCEPHALUS (CPPRH) SCALE.

Dr. Sehrish Altaf

Department of Neurosurgery, Jinnah Postgraduate Medical Centre, Karachi.

Objectives: To predict the development of post resection post fossa tumors in pediatric patients using CPPRH scale and the need for pre resection CSF diversion procedures.

Methods: The cross sectional study conducted from January 2020 and January 2022 at Jinnah Postgraduate Medical Centre (JPMC). Total of 51 pediatric patients of age < 18 years with radiological evidence of posterior fossa tumors were included and all of the CPPRH parameters (age, preoperative radiological diagnosis, presence of moderate/severe hydrocephalus, transependymal edema, and metastatic disease at the time of diagnosis), the need for a CSF diversion procedure at 6 months and management of hydrocephalus were evaluated.

Results: Among 51 patients 39 (76.4%) were males and 12 (23.5%) were females with mean age of 5.5 years. While evaluating CPPRH parameters 28 (54.9%) patients have transependymal edema, 2 (3.9%) have cerebral metastasis, 46 (90.1%) have moderate/severe hydrocephalus and radiologically 28 (54.9%) were ependymoma, 9 (17.6%) medulloblastoma while 14 (27.4%) were gliomas. Majority (46) (90.1%) of patients lie in the CPPRH score 4. On 6 month follow up 22 (43.1%) patients needed csf diversion.

Conclusion: CPPRH score is a valuable tool at the time of first diagnosis of the posterior fossa tumor and is helpful aid in predicting pre resection need for CSF diversion procedures.

Key Words: Posterior fossa tumors, CPPRH.

Clinical outcomes and quality of life after endovascular embolization for Vein of Galen Aneurysmal Malformation (VGAM): A study from a low-and middle- income country

Author Names and Affiliation:

1) Fatima Suleman: Resident, Department of Neurosurgery, Aga Khan University, Hospital, Karachi, Pakistan

2) Ayesha Sohail: Intern, Department of Neurosurgery, Aga Khan University, Hospital, Karachi, Pakistan

3) Gohar Javed: Assistant Professor, Department of Neurosurgery, Aga Khan,University Hospital, Karachi, Pakistan

Dr. Fatima Suleman

Resident, Department of Neurosurgery, Aga Khan University Hospital, Karachi,Pakistan

Abstract:

Introduction: Vein of Galen Aneurysmal Malformations (VGAMs) are high-flow intracranial aneurysms which were previously treated surgically, however, due to high mortality rates endovascular therapy soon took over. The study evaluates the short- and long-term clinical outcomes and quality of life in patients undergoing embolization for VGAMs.

Methods: It’s a retrospective review of patients with VGAM who underwent endovascular embolization at our center between 2000 and 2022. Patients with aneurysms without true malformation, who underwent any angioembolization cycle from another center, or had galenic dural fistulas were excluded. Clinical, radiological, and embolization-related features were noted. King’s Outcome Scale for Childhood Injury (KOSCHI) score was used to evaluate the long-term neurocognitive outcomes, and was classified as: good outcome (KOSCHI=5-4b), poor outcome (KOSCHI=4a-2), and deceased. Rivermead Post concussion Symptoms Questionnaire was used to evaluate quality of life.

Results: The study included seven patients. VGAMs were initially diagnosed in the prenatal period (1/7), childhood (3/7), and adulthood (3/7). They were classified as either choroidal (3/7), mural (3/7), or mixed (1/7). Majority of patients had ventriculomegaly on presentation. The cohort underwent 10 embolization procedures and was advised 1 to 3 stages per patient. One mortality, two poor outcomes, and four good outcomes were reported. Subarachnoid and intraventricular hemorrhage was the main causes of patients’ worsening. Fatigue, irritability, and feeling of frustration were the most common behavioral problems encountered in the long term.

Conclusion: The outcomes after angioembolization for VGAM seem favorable; however, studies with larger sample sizes are required to establish the predictor-outcome association.

Keywords: Vein of Galen Malformation, Therapeutic embolization, Patient Outcome Assessment.

The use of antibiotics in surgical field after Laminectomy and fenestration procedure

Dr. Syed Hanifullah

Ali institute of medical sciences, Peshawar.

Abstract.

Post op infection and Discitis after laminectomy and fenestration procedure is a rare but fearful complication, this study shows the effect of Topical/local antibiotics in surgical field on the outcome of Laminectomy and fenestration procedure.

Material and Method:

This study was conducted in Neurosurgery dept. of Ali institute of medical sciences, Peshawar from February, 2022 till February 2023, in this study all the patients were free of co morbid like DM. The drug used was Vancomycin. The study included 20 males and 20 female patients with the mean age of 37, all the patients were having either stenosis or Disc prolapse ( Group A ). These patients were compared with other 40 patients in whom no antibiotics were used intra operatively in incision site (Group B).

Result.

After a follow up of 2 months for each patient, No patient had discitis in Group A. while in Group B 2 patients had Discitis.

Radiation exposure from C-Arm fluoroscopy during common neurosurgical procedures

Tehniat Khaliq, Iram Bokhari, Farrukh Javeed, Raheel Gohar, Anas Ahmed.

OBJECTIVE:

To estimate the cumulative risk of radiation exposure in neurosurgeons using C-arm fluoroscopy during common neurosurgical procedures and its safe radiation use in the operating room.

MATERIAL AND METHODS:

In this comprehensive study, we monitored radiation exposure in 65 consecutive cases, which involved various common spinal procedures. Prior to commencing the study, we obtained approval from the Institutional Review Board. To measure radiation exposure, we utilized a badge dosimeter positioned under the lead apron at the chest pocket, ensuring shielded whole body exposure. Subsequently, we calculated the corresponding mean and maximum values and conducted a thorough analysis, comparing the data on fluoroscopy time, number of X-ray shots, and effective dose for each individual case.

RESULTS:

In our study, we collected data from 65 patients, including 25 TPS, 17 ACDF, and 23 lumbar discectomy cases. The analysis revealed that, on average, patients undergoing TPS surgery received 16 shots of X- rays, while those undergoing lumbar discectomy received 2.2 shots, and ACDF patients received 3.7 shots. Regarding radiation exposure, TPS surgery resulted in 0.082 mSv, lumbar discectomy 0.065 mSv, and the average radiation in ACDF was 0.071 mSv. However, the overall safe range of radiation was estimated to be between 0.061 mSv and 0.010 mSv.

CONCLUSION:

This study’s result revealed that radiation doses in the common neurosurgical procedures conducted are consistently low and fall well within safe limits. However, it remains crucial to continuously monitor the exposure in various surgical procedures. Furthermore, the reference values established in this study can serve as valuable standards for future audits.

Analysis of variation in radiological parameters in congenital hydrocephalus after ventriculoperitonal shunt placement and its association with the functional outcome

Tehniat Khaliq, Iram Bokhari, Rabail Akhbar, Tanweer Ahmed

BACKGROUND: Despite being a common clinical condition, the long-term outcomes of congenital hydrocephalus are still unclear, and there is a lack of data concerning volumetric changes after diversion procedures.

OBJECTIVE: This study aims to assess the volumetric changes in brain ventricles following successful ventriculoperitoneal shunt surgery and correlate them with clinical improvement.

MATERIALS AND METHODS: This correlation study was carried out at the Neurosurgery department of Jinnah Postgraduate Medical Center, Karachi. A total of 50 patients diagnosed with congenital hydrocephalus, were prospectively recruited and followed upto a period of one year (from 2-8-2021). Radiological parameters, including cortical mantle thickness, Evan's ratio, FH/ID ratio, and size of the temporal horns, were evaluated pre-operatively. Followed by, another CT scan which was done at one year and the same measurements were compared to assess the results. In addition, functional outcome was also assessed by evaluating the developmental milestones, which included motor, sensory, feeding and language development.

RESULTS: Our study included 50 patients, comprising 18 males and 32 females. After one year, we observed changes in the cortical mantle among the patients. Specifically, 14 patients (28%) showed an increase, 29 patients (58%) showed no significant change, and 7 patients (14%) exhibited a decrease in the cortical mantle. Additionally, we inspected Evan's ratio and found that 29 patients (58%) experienced a decrease, 14 patients (28%) had an increase, and 7 patients (14%) showed no significant change. Regarding the FH/ID ratio, we observed that 15 patients (30%) had a decrease, 7 patients (14%) had an increase, and 28 patients (56%) showed no significant change. Moreover, the size of the temporal horn reduced in 17 patients (34%) and varied in others.

CONCLUSION: Early CSF diversion and timely intervention did not appear to improve any radiological parameters or functional recovery. Therefore, the role of VP shunt placement in enhancing the functional outcome requires further long-term analysis for better understanding of the disease prognosis.

Evolution of 3D Reconstructed Acrylic Cranial Implants and Cranioplasty: An Institutional Experience at the Punjab Institute of Neurosciences, Lahore

Objective: To evaluate patients having 3D reconstructed cranial augmentation postoperatively in terms of their cosmetic results and post-operative complications at the Punjab Institute of Neurosciences in Lahore.

Materials and Methods: This is a retrospective review of 22 patients who underwent 3D reconstructed cranial augmentation using acrylic cranial implants from June 2021 to June 2023. Preoperatively, these patients were evaluated clinically and radiologically by 3D reconstructed CT scan of the brain to assess the contours, cosmesis, and complications. Patients were also reviewed at 1 month and 3 months for any delayed post-operative complications.

Results: We found that out of 22 patients, 20 had excellent cosmetic results in terms of skull contour and cosmesis. Two patients had temporal dip due to temporalis muscle atrophy. Regarding post-operative complications, one patient had a CSF leak followed by a CSF infection, and the implant was removed. One patient developed extradural collection on the 9^th post-op day; he was reexplored, the same implant was placed, and the patient remained well and was discharged.

Conclusions: 3D-reconstructed cranial implants are the future of cranial and craniofacial reconstruction surgeries with excellent cosmetic results. As it is a unique study using 3D reconstructed skull implants, we need to work on it to improve our technique. Pre-designed 3D skull implants effectively reduced intraoperative time and manipulation with acceptable cosmetic results both for the patient and surgeon.

Key Words: Cranioplasty, 3D Reconstructed Cranioplasty, Acrylic Cranial Implant, Decompressive Craniectomy, 3D Cranial Implants.

Comprehensive Analysis of Speech and Motor Impairments in Low-Grade Glioma Surgery within the Eloquent Cortex: Integrating Exoscopic Neuronavigation, Functional MRI, & Tractography at Punjab Institute of Neurosciences, Lahore

Shahzad Hussain Shah1, Adeeb Ul Hassan2, Mian Aamir Fiaz3, Hamza Noman4

Professor & Head of Neurosurgery Unit II Punjab Institute of Neurosciences Lahore
Senior Registrar, Neurosurgery Unit II, Punjab Institute of Neurosciences Lahore
Resident Neurosurgery, Neurosurgery Unit II, Punjab Institute of Neurosciences Lahore
Resident Neurosurgery, Neurosurgery Unit II, Punjab Institute of Neurosciences, Lahore

Presenter: Dr. Mian Aamir Fiaz

Abstract:

Objective: The objective of this research is to conduct a thorough analysis of speech and motor impairments in patients undergoing surgery for low-grade gliomas within the eloquent cortex. This analysis will involve the integration of advanced techniques such as exoscopic neuronavigation, functional MRI, and tractography at the Punjab Institute of Neurosciences in Lahore. The primary goals of the study is to assess the extent and nature of speech and motor deficits in patients with low-grade gliomas located within the eloquent cortex.

Material & Methods: In this study, a cohort comprising 10 patients was analyzed, consisting of 6 males and 4 females, with ages falling within the range of 20 to 45 years. Data collection spanned from February 2023 to September 2023. Prior to surgical intervention, all patients underwent comprehensive preoperative imaging assessments. This imaging protocol encompassed MRI scans employing a neuronavigation Protocol, Functional MRI investigations targeting the Speech and Motor cortex, and Diffusion Tensor Imaging. To evaluate speech and motor function, assessments were performed on all patients both before and after surgery, with follow-up evaluations conducted at 1 month and 3 months postoperatively.

Results: Preoperatively, all 10 patients exhibited intact neurological function. However, in the postoperative phase, 3 patients experienced speech impairments, while 2 patients manifested motor weaknessimmediate post operatively. Notably, these deficits exhibited an encouraging trend toward gradual improvement, ultimately reaching a state of normalcy over a span of 3 months.

Conclusion: In conclusion, our comprehensive analysis of speech and motor impairments in low-grade glioma surgery within the eloquent cortex, coupled with the integration of advanced technologies such as exoscopic neuronavigation, functional MRI, and tractography, underscores the pivotal role these methodologies play in preserving neurological function postoperatively.Our findings highlight the significance of these cutting-edge techniques in facilitating the preservation of critical brain regions and, consequently, the neurological status of patients undergoing surgery for low-grade gliomas within eloquent cortex areas. This study reinforces the importance of adopting a multidisciplinary approach that harnesses the power of modern neurosurgical tools to enhance patient outcomes and quality of life in the context of such complex surgical interventions.

KEYWORDS: Speech deficits, Motor deficits, Low grade gliomas, exoscope, neuronavigation, functional MRI, Tractography.

Day Case surgeries in Neurosurgery: A paradigm shift in surgical approach for neurosurgical cases

Dr. Mubashir Malik

Consultant Neurosurgeon

Punjab Institute of Neurosciences Lahore Pakistan.

Abstract

Introduction:

In recent years, the field of neurosurgery has witnessed a remarkable transformation in the way surgical procedures are performed and managed.

Objectives:

The basic aim of the study is to find the impact of day case surgeries in neurosurgery as a paradigm shift in surgical approach for neurosurgical cases.

Material and methods:

This study is designed as a case series study to comprehensively investigate the application of day case surgeries in the field of neurosurgery. The primary objective is to assess the impact of day case surgery technique and technologies in a cohort of 1000 neurosurgical cases. The study population comprises 1000 consecutive cases of patients who underwent neurosurgical procedures at Punjab Institute of Neurosciences Lahore Pakistan and Masood hospital Lahore Pakistan between May 2022 to May 2023.

Results:

Data was collected from 1000 patients of neurosurgery and spine surgery. The mean age of patients undergoing neurosurgery was 54.2±12.5 years, while patients undergoing spine surgery had a mean age of 49.8±14.3 years. Gender distribution in neurosurgery showed 160 male and 151 female patients, while in spine surgery; there were 324 male and 365 female patients. Co morbidities were present in a significant proportion of patients. In the neurosurgery group, 37% had co morbidities, such as hypertension and diabetes, while in the spine surgery group, 30.8% had co morbidities.

Conclusion: It is concluded that day-case neurosurgery is feasible in our environment. With careful patient selection and adequate pre-operative preparation, good outcome can be achieved.

A case report of cerebellar ganglioglioma and review of literature: A case report.

Danyal Nazir, Ayesha Sohail, , Saqib Kamran Bakhshi, Ahmad Gilani,

Abstract:

Cerebellar gangliogliomas are rare benign brain tumors and very few cases are reported in literature so far. We report a case of a 43 years old male patient who underwent a ventriculoperitoneal shunt for hydrocephalus and presented to us with complaints of headache, blurring of vision and gait disturbance. Posterior fossa craniotomy was done and the tumor was resected. A WHO grade 1 cerebellar ganglioglioma was diagnosed on histopathological analysis.

OUTCOME OF ENDOSCOPIC PITUITARY SURGERY

MUSADIQUE LATIF, LAL REHMAN

ABSTRACT

Background: Endoscopic pituitary surgery has emerged as a leading surgical approach for the treatment of various pituitary disorders. The aim of our study is to review the outcomes of endoscopic pituitary surgery, focusing on efficacy, complications, and future perspectives.

METHOD: Patients with pituitary adenomas operated through endoscopic pituitary surgery at Department of Neurosurgery, Pakistan Institute of Medical Sciences, Islamabad from August 2022 to august 2023 were included in this study. Dempgraphic, endocrinologic and radiologic features and their outcomes were sequentially assessed in these patients. The data was analyzed through SPSS V 25.

Results: Out of 20 patients, 12 were males and 8 were females. Age range in our study was 21- 45 years. 13 were the secretory adenomas and 7 were non-secretory adenomas. Out of the 13 adenomas which were secretory, all had presented with acromegaly. Mean follow up period was 3 months. Visual improvement was observed in all patients in the immediate postoperative period. Radiation and Medical therapy were pertinent to achieve biochemical cure in secretory adenomas and all patients showed improvement at par. One patient had cerebrospinal fluid leak, which was managed accordingly. There was no death seen.

Conclusion:The minimally invasive nature of the endoscopic pituitary surgery allows for improved visualization and precision in tumor resection, contributing to high rates of gross total resection and favorable outcomes. Advances in surgical techniques, perioperative care, and meticulous surgical planning have significantly reduced the incidence of complications, further enhancing the safety and tolerability of the procedure.

KEY WORDS: Pituitary adenomas, endoscopic surgery, cerebrospinal fluid leak.

OUTCOME OF SURGICAL CLIPPING IN IN INTRACRANIAL ANEURYSMS

MUSADIQUE ATIF, LAL REHMAN

ABSTRACT

Background:

Surgical clipping has been a longstanding and established treatment modality for intracranial aneurysms.The aim of our study was to assess outcomes of surgical clipping, focusing on efficacy, complications, and prognostic factors.

Method:

Patients who underwent clipping of the aneurysms at Department of Neurosurgery, Pakistan Institute of Medical sciences, Islamabad from January 2023 till August, 2023 were included in this study. Outcome was assessed on Radiologic and neurologic basis Pre and postoperatively respectively. Data was analyzed using SPSS v 25.

Results:

Out of 10 cases, 2 were males and 8 were females. Age range in our study was 35 to 60 years. All patients had presented with subarachnoid hemorrhage and surgery was delayed until after 14 days of ictus. 6 were the anterior communicating artery aneurysms and 4 were the middle cerebral artery aneurysms. All patients were operated through the pterional approach, 7 on right side and 3 on left side. All patients were discharged in GCS 15. Complications in the form of disability or death has not been reported so far.

Conclusion:

Surgical clipping for intracranial aneurysms highlights its efficacy and safety in preventing rebleeding, achieving successful aneurysm occlusion, ensuring improved outcomes and patient quality of life.

KEY WORDS:

Subrachnoid hemorrhage, intracranial aneurysms, surgical clipping.

PATTERN OF SPINAL INJURIES

MUSADIQUE LATIF, LAL REHMAN

ABSTRACT

Background: Trauma is the leading cause of hospitalization globally and trauma-induced spinal injuries can be devastating and permanent. The aim of our study is to identify the pattern and outcome of traumatic spine injuries.

Method: Patients with traumatic spinal fractures presenting at Department of Neurosurgery, PIMS, Islamabad from August 2022 to September 2023 were included in the study. Patients with osteoporotic or metastatic collapse, isolated transverse or spinous process fracture, penetrating trauma or ballistic injuries were excluded. The data was analyzed using SPSS V 25.

Results: Out of 134 enrolled patients, 86 were males and 48 were females. The maximum number of spine trauma patients was in 25–40 years age group. The most common mechanism of injury was road traffic accidents (RTA, 44.6%) followed by fall from height (FFH, 30.3%). RTA was more common among males and FFH among females. Most common location of injury was at thoracolumbar junction (D10-L2) (40.2%) followed by cervical spine (28.12%). 56.7% of patients had stable fractures and 43.2% had unstable fracture. Complete neurological deficit (ASIA grade A) was seen maximum in distraction fractures (77.7%) followed by rotation (26.08%).

Conclusion: Young aged males in age group of 25–40 years were most commonly affected with road traffic accidents as the most common mechanism of trauma. Association was found between gender and mechanism of injury (RTA in males and FFH in females). Most common vertebral injury level was thoracolumbar junction. Compression fracture was the most common fracture morphology. Statistically significant association was found between complete SCI with Fracture morphology (distraction fractures).

Key Words: Injury pattern, Road traffic accidents, male gender, compression fractures.

OUTCOME OF PEDIATRIC HEAD INJURIES

Musadique Latif, Lal Rehman

Abstract.

Objective: The aim of this study was to assess the outcome of pediatric head injury at a tertiary care hospital.

Methods: A total of 312 children with age ≤ 14 years with head injury admitted at Department of Neurosurgery, PIMS, Islamabad from August 2022 to August 2023 were included in the study. Patients were followed up for duration of 3 – 6 months. Data was analyzed using SPSS v 25.

Results: The average age in our study was 9 years and majority (74.35%) were males. The most common presenting feature was altered sensorium. The average duration of hospitalization in our study is 4 with 80% of patients staying < 7 days. Most common mechanism of head injury in children was fall from height. Most common type of injury was extradural hematoma. Mortality rate is low as compared to all head trauma victims.

Conclusion: Outcome of pediatric head injury depends on initial presentation. Early recognition and prompt management contributes to decrease mortality and disability. Younger males are at a greater risk. Most injuries are mild-to-moderate in nature with high rate of good recovery.

Key Words: Pediatric head injury, Extradural hematoma, Glasgow outcome score.

Patient-Reported Outcomes and Complications of Simultaneous Versus Staged Surgical Decompression for Tandem Spinal Stenosis.

Mustafa Mushtaq Hussain, Mujtaba Khalil, Fatima Suleman, Iqra Fatima, Mehar Masroor, Muhammad Shahzad Shamim.

Author names and affiliations:

1) Mustafa Mushtaq Hussain, Resident, Department of Neurosurgery, Aga Khan University Hospital, Karachi, Pakistan

2) Mujtaba Khalil, MD, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH. ORCID id: 0000-0001-8461-2677

3) Fatima Suleman, Resident, Department of Neurosurgery, Aga Khan University Hospital, Karachi, Pakistan. ORCID id: 0000-0002-7035-1047

4) Iqra Fatima Munawar Ali, Medical Student 4 th Year, Aga Khan University Hospital, Karachi, Pakistan

5) Mehar Masroor, Resident, Department of Neurosurgery, Aga Khan University Hospital, Karachi, Pakistan

6) Muhammad Shahzad Shamim, Professor, Department of Neurosurgery, Aga Khan University Hospital, Karachi, Pakistan

ABSTRACT

Introduction: Tandem Spinal Stenosis (TSS) is a clinical condition with narrowing of the spinal canal diameter in two distinct anatomic areas. TSS can present with polyradiculopathy, sensorimotor deficits, gait disturbances, and incontinence that can be due to cervical myelopathy or lumbar stenosis. Although both conditions require surgery, deciding which anatomical level is symptomatic and need to be treated first is sometimes difficult. The authors aimed to identify the best surgical approach for TSS.

Methods: The authors performed a retrospective study which included patients who underwent simultaneous or staged decompression surgery for TSS over 10 year period (January 1, 2011, and December 31, 2020). Patient records were reviewed to collect data on demographics, type of procedure, modified Japanese Orthopedic Association (mJOA) score, and complications. The authors employed mJOA scale to quantify the neurological status. Statistical analysis was done using SPSS (version 21).

Results: Forty two patients met the inclusion criteria and were divided into two groups. The first group included 33 patients who underwent simultaneous cervical and lumbar decompression, while the second cohort included 9 patients with decompression in two stages (cervical followed by lumbar procedure). Simultaneous cervical and lumbar decompression resulted increased blood loss [676.97 ml vs 584.44 ml] and a greater need for transfusion[259.09 ml vs 111.11 ml], but this did not reach significance. Operating time [429.11 mins vs 288.42 mins; p= 0.005] was significantly higher in the staged decompression group. The rate of complications was higher in the simultaneous group (10 vs 1; p=0.024). Post-operative mJOA scores improved in both groups, but the improvement was more pronounced in the staged group (15.16 ± 2.18 vs 16.56 ± 1.59), however, this did not reach significance. Overall, the hospital stay in the simultaneous group was 4.22 days with a recovery rate of 59.75%. In contrast, the staged group had a higher hospital stay of 6.09 days with a better recovery rate of 78.20%.

Conclusion: The patient’s clinical history and examination findings should be the main determinants of surgical decision-making. Our study showed a slightly higher postoperative mJOA score and the recovery rate with lesser complications in staged decompression of TSS.

Keywords: Tandem spine stenosis, surgical approach, surgical outcomes.

Unusual presentation of Frontal bone Osteoma; A case report and literature review

Danyal Nazir¹Ayesha Sohail², Faizan Saeed², Saman Amin³, Anam Tariq⁴, Altaf Ali Laghari^*

Corresponding Author: Altaf Ali Laghari.

Abstract:

Intracranial osteomas are rare, slow growing, non malignant bony abnormalities that are often symptomatic and are incidentally found on imaging. Here in, we report a case of a 50-year-old gentleman, who presented with the complaint of right upper extremity weakness and eventually was diagnosed with left frontal bone osteoma extending up to the dura of left frontal lobe. Radical excision was performed after which he showed remarkable improvement. This study includes review of the relevant literature and possible management strategies for intracranial osteoma.

Children with diastematomyelia have good postoperative quality of life; results from an Asian country

Authors:

Mehar Masroor, Aga Khan University Hospital, Karachi.
Quratulain Virani, Aga Khan University Hospital, Karachi.
Malaika Siddiqui, Aga Khan University Hospital, Karachi.
Muhammad Shahzad Shamim, Aga Khan University Hospital, Karachi.
Saqib Kamran Bakhshi, Aga Khan University Hospital, Karachi.

Resident (PGY-2) in Section of Neurosurgery, Aga Khan University Hospital, Postal address: III-F 12/17, 3 rd floor, Nazimabad no. 3, Karachi. (Email: mehar36369@gmail.com).

Abstract:

Introduction: Diastematomyelia can be associated with neurological deficits and disability. Surgical treatment is aimed at de-tethering the spinal cord. Quality of life can be significantly affected, but limited evidence is available. Purpose To evaluate the quality of life at follow-up in patients surgically treated for diastematomyelia.

Materials and Methods: This was a retrospective cohort study. Data was collected by reviewing the medical records of patients with diastematomyelia being operated between 1 st July’ 2012 and 31 st July’ 2022 in a single center and a Health Utility Index-3 (HUI-3) scoring was completed by the guardian/family member to rate quality of life.

Results: A total of 25 patients were included. The median age of patients at time of presentation was 7 (IQR: 1.4 – 11.5) years. Females were nearly twice in numbers than males (17; 68%). Nineteen patients (76%) had a normal motor neurological function at presentation (Modified McCormick grade I). The most common anatomic level of diastematomyelia was lumbar (12, 48%) followed by lumbosacral (5, 20%). Bony spur arising from the lamina was the most common reason for splitting the cord (16; 64%). The neurological status over time improved or remained static in 21 patients (84%) while 1 patient was observed to have worsening of neurological status over time (4%). The median follow- up time postoperatively was 3.3 years (IQR: 2 – 6). The mean HUI3 score (out of 1) for 21 children was 0.93 ± 0.24.

Conclusions: Our results suggest that surgical management of diastematomyelia is associated with good long term quality of life.

Key words: Diastematomyelia, Long-term quality of life, Pediatric Neurosurgery.

Outcomes of Orbital tumors treated with Single and Multisession Gamma knife Radiosurgery

Aurangzeb kalhoro, Kashif Ahmed, Abdul Sattar M. Hashim

Pakistan Gamma knife Centre, NCCI , Karachi.

Abstract:

Objective: This study aims to analyse the results of treating orbital tumors using Gamma Knife radiosurgery (GKRS).

Patients and Methods: This study retrospectively analyzed 46 patients with orbital tumors treated using GKRS between January 2008 and July 2022 at the Neurospinal and Cancer Care Institute in Karachi. The cohort comprised 22 males and 24 females, aged 16 to 90 years. Diagnoses were confirmed through pathology for 22 patients; for 24 others, diagnoses relied on clinical and imaging findings. Tumor types included 17 meningiomas, 12 optic nerve gliomas, 6 schwannomas, 4 orbital cavernous hemangiomas, 2 orbital lymphomas, 2 orbital AVMs, 2 orbital metastases, and 1 carotid cavernous fistula case. Target volume ranged from 1.7 to 15.87 cm³. Tumor margin dose varied from 12 to 25 Gy. Of these, 24 cases received single-session GKRS (Dose range 12-15 Gy), while 22 patients with intact vision and tumors near the optic nerve received 3 to 5 days multisession treatment (Dose range 15-25 Gy).

Results: The follow-up period ranged from 3 to 48 months of radiological assessments. Successful tumor control was achieved in 44 cases (95.6%). Tumor volume reduction was observed in 60.8% (28 cases). Improvements in visual function were noted in 52% (24 participants), while 17.4% (21 participants) maintained stable Vision. One patient developed reduced visual acuity, and 2 patients experienced recurrences. Multisession GKRS yielded favorable outcomes, with excellent tumor control in all patients with reduction in tumor volume noted in 73% (16 cases). Orbitocavernous hemangioma cases treated with Multisession GKRS achieved greater degree of tumor shrinkage in all 4 cases (P < 0.05).

Conclusion: Gamma Knife radiosurgery offers effective management of orbital tumors while maintaining neurological function. Employing a multi-session GKRS approach provides greater degree of tumor shrinkage, preserves visual function and sustained tumor control.

Key Words: Gamma Knife Radiosurgery, Orbital tumor, Multisession Gamma knife radiosurgery.

Frequency of Post-operative CSF Diversion in Patients with Third Ventricular Colloid Cyst: A Single Center Retrospective Analysis

Syeda Kubra Kishwar Jafri 1 , Ahmer Nasir Baig 2 , Mishkat Shehzad 2 , Saqib Kamran, Bakhshi 2 , Muhammad Shahzad Shamim 2

Memon Medical Institute Hospital, Karachi
Aga Khan University Hospital, Karachi

Presenter: Dr. Ahmer Nasir Baig

Affiliation: Aga Khan University Hospital Karachi

Address: Aga Khan University Hospital, Stadium Road Karachi

Email: ahmer.baig@aku.edu

Introduction: Patients operated for third ventricular colloid cyst (TVCS) may have symptomatic postoperative hydrocephalus requiring CSF diversion. Several risk factors have been predicted but the definitive evidence is scarce.

Objectives: We evaluated the need for permanent CSF diversion in patients operated for third ventricular colloid cyst (TVCS).

Methods: This was a retrospective chart review of patients who were operated on for a TVCS over 13 years at a single tertiary care center in LMIC. Data was collected on pre-formed proformas by reviewing hospital records and follow-up data for up to one year was recorded.

Results: Headache was the most common presenting symptom (92.7%). The mean cyst volume was 1.89cm3 (IQR: 2-5). Hydrocephalus was found in 54 (98.2%) of imaging studies. Nineteen (34.5%) patients were operated on via transcortical open microsurgical approach, while 34 (61.8%) underwent transcortical endoscopic, 2 (3.6%) underwent transcallosal excision of the colloid cyst. Eleven (20%) patients had an endoscopic third ventriculostomy. Three (5.5%) patients had a temporary CSF diversion procedure preoperatively, while 47 (85.5%) needed temporary CSF diversion at primary surgery. Gross total excision was achieved in 47 (85.4%). Postoperative hydrocephalus was found in 20 (34.5%) postoperative scans. CSF leak (20%) was the most common complication. The median length of hospital stay was 8 days (IQR: 5-10). Permanent CSF diversion by means of VPS was needed in 8 (14.5%) patients.

Conclusions:Even though the rate of CSF diversion is high, we could not identify any significant predictors of need for VP shunt insertion in patients undergoing TVCS

Keywords: CSF diversion, Hydrocephalus, Third ventricular colloid cyst.

Institutional experience for outcome of micro surgical clipping of ruptured intracranial aneurysm at Punjab Institute of Neuroscience, Lahore

Shahzad Hussain Shah1, Hassan Ali khosa2, Asad Iftikhar Shah3, Mustapha Shesh4

Professor & Head of Neurosurgery Unit II Punjab Institute of Neurosciences Lahore
Senior Registrar, Neurosurgery Unit II, Punjab Institute of Neurosciences Lahore
Senior Registrar, Neurosurgery Unit II, Punjab Institute of Neurosciences Lahore
Resident Neurosurgery, Neurosurgery Unit II, Punjab Institute of Neurosciences, Lahore

Presenter: Dr. Mustapha Shesh

Abstract:

Objective: Microsurgical clipping has become the gold standard for treating ruptured intracranial aneurysms. The aim of our study is to report our experience with outcome of microsurgical clipping for ruptured intracranial aneurysm (IA).

Materials & Methodology: A retrospective study of 99 patients ( 60 female and 39 male) with ruptured intracranial aneurysms who underwent micro surgical clipping after 2 weeks of ictus from 1st September 2022 to 14th September 2023 at Punjab institute of neuroscience’ in Neurosurgery unit II. Outcome analysis was done using medical records and DICOM for postoperative complications, any evidence of vasospasm, infarction or bleed, hydrocephalus and Glasgow outcome scale.

Results: Successful microsurgical clipping was possible in 93 patients with 6 having per operative rupture. WFNS at the time of presentation was between I-III in 80% of patients. 7 patient developed clinical vasospasm and 5 out of them had established infarct at 2 in right MCA, 1 in left MCA and 2 in right ACA territory. 1 developed post-operative ICH and 4 postoperative hydrocephalus. Glasgow outcome scale of our patients were I in 60, II in 23 , III in 5, V in 5 and VI in 6

Conclusion: Microsurgical clipping of ruptured aneurysm is safe in patients after the vasospasm period is over and has good Glasgow outcome scale. The identification of surgical complications may encourage the search for solutions to improve surgical treatment of aneurysmal SAH (subarachnoid hemorrhage).

Keywords: Microsurgical clipping, ruptured intracranial aneurysm, SAH (subarachnoid hemorrhage), vasospasm, hydrocephalus.

To determine the frequency of neural tube defects in children at PMCH Nawabshah

ABSTRACT. (Dr. Naimat Shar)

OBJECTIVE: To determine the frequency of neural tube defects in children at PMCH Nawabshah.

MATERIAL AND METHODS

SETTING: This study was performed in Neurosurgery department at PUMHS for women, Nawabshah – SBA.

STUDY DESIGN: This is a Cross sectional study

STUDY DURATION: 6 months followed by synopsis approval

Inclusion Criteria: All the newly born neonates presented with neural tube defects, either of gender were included.

DATA COLLECTION: Complete clinical examination was done. Maternal information was done regarding occupational status, socioeconomic status, parity, gestational age, folic acid consumption history and family history. All the data including neural tube defects were recorded in the self-made proforma. The statistical program SPSS 26.0 was used for all data entry and analysis.

Results: A total of 125 cases were studied; maternal mean age was 32.27+5.48 years. Most of the cases 80.0% were from rural areas. Out of all 79.2% were poor socioeconomically. Majority of the women 89.6% were house wives. 4.8% of cases were found with previous neural tube defect children. Folic acid supplementary history during antennal care was only in the 8.0% of the women. Most of the cases 37.6% had Myelomeningocele, 13.6% had spinal bifida and 12.0% had both spinal bifida and hydrocephalus, followed by 9.6% cases had Encephalocele, 8.8% had meningocele, 4.8% had atrophy and 1 case was of encephalocele + hydrocephalus. Neural tube defects were statistically significant according to the maternal age and folic acid supplementary history (p= <0.05), while statistically insignificant according to the residential status, socioeconomic status, parity and previous history of disease (p= >0.05).

Conclusion: As per the study conclusion the most common neural tube defects were observed to be the spinal bifida and encephalocele. Folic acid supplementary history seems to be very low. These findings underscore the significance of understanding and addressing these conditions within the context of public health and medical interventions.

Key words: Neural tube defects, Frequency, Folic acid supplement.

Evaluating the Feasibility and Reliability of Different Techniques for Cerebral Microdialysis Catheter Placement at Punjab Institute of Neurosciences Lahore

“Shahzad Hussain Shah1, Imran Ali2, Rizwan Khan3, Hafiz Natiq Bilal4

Head of Neurosurgery Unit II Punjab Institute of Neurosciences Lahore
Senior Registrar, Neurosurgery Unit II Punjab Institute of Neurosciences Lahore
Senior Registrar, Neurosurgery Unit II Punjab Institute of Neurosciences Lahore
Resident Neurosurgery, Neurosurgery Unit II Punjab Institute of Neurosciences Lahore

Presenter: Dr. Hafiz Natiq Bilal

Abstract:

Objective: To assess the complications, feasibility, and reliability associated with the placement of a microdialysis catheter in neurocritical patients.”

Methods: This retrospective study investigates the use of cerebral microdialysis at the Punjab Institute of Neurosciences from November 2022 to September 2023. It offers a detailed exploration of the technical aspects involved in different methods used to place microdialysis catheters, supported by comprehensive descriptions.

Results: “In this study, we deployed twenty microdialysis catheters for twenty patients. Thirteen catheters were inserted using a single-lumen bolt and twist drill at the bedside, with ten administered under local anesthesia and three under light sedation. Conversely, seven catheters were positioned via burr hole under deep sedation, necessitating an emergency operating theater. Two catheters required re-adjustment or replacement due to dislodgment. Our findings within the initial 48-hour period revealed a markedly higher reliability for percutaneous implantation as opposed to burr hole importantly, a substantial disparity in both feasibility and reliability favored the percutaneous approach using a bolt and twist drill over the traditional burr hole method, underscoring its superior performance.”

Conclusion: “In conclusion, our study underscores the advantages of percutaneous implantation of cerebral microdialysis catheters through twist-drill craniostomy, including reduced complications, improved reliability, and excellent feasibility. These findings provide compelling evidence to encourage surgeons to consider adopting or expanding the use of cranial bolt placement via twist drill for cerebral microdialysis procedures.”

Keywords: Cerebral Micro Dialysis, Burr Hole, Traumatic Brain Injury, Twist Drill.

Early Institutional Experience of Microvascular Decompression for Trigeminal Neuralgia Using a 3-Dimensional Exoscope: A Case Series

Shahzad Hussain Shah1, Omair Afzal2, Muhammad Yousaf 3, Muhammad Ovais Zafar4

Head of Neurosurgery Unit II Punjab Institute of Neurosciences Lahore
Senior Registrar, Neurosurgery Unit II Punjab Institute of Neurosciences Lahore
Senior Registrar, Neurosurgery Unit II Punjab Institute of Neurosciences Lahore
Resident Neurosurgery, Neurosurgery Unit II Punjab Institute of Neurosciences Lahore

Presenter: Dr. Muhammad Ovais Zafar

Abstract:

Introduction: Detailed anatomic visualization of the root entry zone of the trigeminal nerve is crucial to successfully perform microvascular decompression surgery (MVD) in patients with trigeminal neuralgia.

Objective: To determine advantages and disadvantages using a 3-dimensional (3D) exoscope for MVD surgery.

Methods: A 4K 3D exoscope was used by a single surgical team for MVD in a case series of 10 patients From Jan 2023 to September 2023 with trigeminal neuralgia in Punjab Institute of Neurosciences Lahore. Clinical and surgical data were collected, and advantages/disadvantages of using the exoscope for MVD were recorded after each surgery. Descriptive statistics were used to summarize the data.

Results: Adequate MVD of the trigeminal nerve root was possible in all patients by exclusively using the exoscope. It offered bright visualization of the cerebellopontine angle and the root entry zone of the trigeminal nerve that was comparable with a binocular operating microscope. The greatest advantages of the exoscope included good optical quality, the pronounced depth of field of the image for all observers, and its superior surgeon ergonomics. Disadvantages were revealed with overexposure at deep surgical sites and the lack of endoscope integration. In these patients, facial pain improved significantly after surgery (Barrow Neurological Institute pain intensity score I in 8 and III in 2 patient), whereas in 2 patients there was grade ll facial palsy.

Conclusion: Utilization of a 3D exoscope for MVD is a safe and feasible procedure. Surgeons benefit from better ergonomics, excellent image quality, and an improved experience for observers.

Keywords: Microvascular Decompression, 3D Exoscope, Trigeminal Neuralgia.

Spinal Dysraphism Clinical Presentations and Treatment Approach – Punjab Institute of Neurosciences, Lahore

Shahzad Hussain Shah1, Hassaan Zahid2, Hassan Ali Khosa3, Bakht Nawaz4

Head of Neurosurgery Unit II Punjab Institute of Neurosciences Lahore
Assistant Prof Pediatric Neurosurgery, Punjab Institute of Neurosciences Lahore
Senior Registrar, Neurosurgery Unit II Punjab Institute of Neurosciences Lahore
Resident Neurosurgery, Neurosurgery Unit II Punjab Institute of Neurosciences Lahore

Presenter: Dr. Bakht Nawaz

Abstract:

Objectives: Spinal Dysraphism is a broad terminology encompassing a heterogeneous group of congenital spinal anomalies that result from defective closure of neural tube early in fetal life. Surgery offers the only treatment, it helps to restore the anatomy and improve the disease outcome. We present herein the results of our institutional experience of clinical profiles, image findings and surgical outcomes of patient that were treated for Spinal Dysraphism and showed significant improvements.

Methods and Materials: A retrospective review of 25 patients who presented with and received treatment for Spinal Dysraphism from March 2023 till September 2023 at Punjab Institute of Neurosciences (PINS), Lahore. After a detailed clinical evaluation of the patient MRI brain was the preferable mode of investigation.

Results: out of the 25 admitted 13 were a case of Diastematomyelia , 8 were type 1, while 5 were type 2. Other presentations included Meningocele, Myelomenigocele, Tethered cord and Subcutaneous lipomas. All were operated upon. 8 patients showed motor and sensory improvements. 2 showed neurological deficit. 2 had CSF leak. 1 patient developed wound infection, while 1 developed neurogenic bladder.

Conclusion: Spinal Dysraphism is a complex disorder and requires a multidisciplinary approach for management. The present study suggests that surgery is the prominent treatment along with good post-operative care for the better life of the patient. Keywords: Spinal Dysraphism , tethered cord , meningomylocele.

Keywords: Spinal Dysraphism, Meningocele, Myelomenigocele, Diastematomyelia.

NORMATIVE SCORE AND CUT OFF VALUE OF ODI IN PATIENTS WITH LOWER BACK PAIN WITH AND WITHOUT DISABILITY IN PAKISTANI POPULATION

Dr.Shuja Shaukat

Department of Neurosurgery, Civil Hospital/Dow University of Health Sciences, Karachi, Pakistan.

Abstract

Objective: To determine the normative score and cut off value of ODI in patients with lower back pain with and without disability in Pakistani population

Background: Low back pain (LBP) is a prevalent health issue affecting a significant portion of the adult population worldwide, with non-specific LBP accounting for a substantial majority of cases. In Pakistan, LBP is a widespread health concern, with a one-month prevalence of 30.6%. The Oswestry Disability Questionnaire (ODQ) has been a commonly employed tool to assess LBP-related disability, yielding the Oswestry Disability Index (ODI) ranging from 0 to 100. Despite the use of the ODI, there remains a gap in understanding its normative score adjusted for age distribution and cut-off values indicative of disability.

Methods: A cross-sectional study design was implemented at SMBBTC, DUHS, Karachi. Participants aged 18 to 70, presenting with LBP, were included in the study. Demographic and clinical data was collected, including age, duration of back pain, smoking status, and comorbidities. Patients were categorized into normal, LBP with disability, and LBP without disability groups as per operational definitions. ODI scores were calculated and recorded.

Results: The normative ODI score within the normal population was found to be 4.62, whereas individuals experiencing LBP displayed a normative score of 37.48. Among the LBP patients, those without disability exhibited an ODI score of 30.00, whereas those with disability demonstrated a substantially higher score of 66.90.

Conclusion: The findings of this study provide a valuable insight into the normative ODI score adjusted for age distribution in the Pakistani population, as well as a clinically meaningful cut-off value to distinguish between individuals with and without LBP-related disability.

Keywords: lower backpain, Oswestry disability index, cut off value, normative value, Disability.

Neuro-Axis Radiation Therapy-An Essential Tool for Neurosurgical Indication

Azhar Rashid, Muhammad Ali Memon, Asad Zameer, A Sattar M Hashim.

Clinical & Radiation Oncology Department. Pakistan Gamma Knife & Stereotactic Radiosurgery Center,

Neurospinal & Cancer Care Institute, Karachi, Pakistan.

Objective: To emphasize the significance of Neuro-Axis (Craniospinal Irradiation–CSI) as an essential tool for neurosurgical Indications.

Introduction: Neuro-Axis (Craniospinal Irradiation–CSI) is a key indication for various neurosurgical pathologies to achieve curative goals of multi-model management. Many of the Pediatric brain tumors and adult brain tumor patients require CSI and concurrent chemotherapy. To accomplish this task without major side effects, modern radiotherapy equipment and techniques played an important role. Techniques like Intensity Modulated Radiotherapy IMRT and VMAT – Volumetric Modulated Arc Therapy that provides steep dose gradient without harming the closely situated normal organ at risk. VMAT offers quick delivery of complex conformal plans. A modern linear accelerators (Synergy-Agility and Synergy-S (mirror Image), Elekta: Crawley UK) with micro multileaf collimators (mic-MLCs- 5 mm), cone beam CT, robotic couch and rapidly calculating Treatment Planning System (Monaco)has made it possible to develop highly conformal plans with minimal radiation toxicity.

Methods: From 11.02.15 to 23.11.21, twenty nine patients of various brain tumors were treated with CSI technique. 06 were female and 23 were male patient. Mean age was 36 years (range: 6- 58 years). All patients were having histopathology proven diagnosis. 18 were diagnosed with medulloblastoma,9 with ependymoma and 2 with germ cell tumor. 14 Patients were pediatric age group and 15 were adults. Standard doses for high risk and standard risk medulloblastoma were used. Chemotherapy weekly Vincristine was used for all the medulloblastoma cases, so CBC was done every week.

Results: All patients tolerated treatment very well with grade II myelosuppression and mucositis was observed in all the patients. Two pediatric patients got grade 3-4 myelosuppression but recovered well with GCSF support.

Excellent Improvement in performance status was observed at first 6 weeks follow-up. Median follow-up time was 36 months (3- 48 months). Over long-term follow-up, 04 patients recurred within first two years. Three in brain and one in spine. Re-treatment with chemotherapy or Stereotactic radiotherapy was carried out. Five Patients were expired at 3 years time. Mostly patients are following up with endocrinologist.

Conclusion: Neuro-Axis (Craniospinal Irradiation–CSI) is an essential treatment option for certain brain tumor management to improve survivals. Routine adaptation of CSI with VMAT may offer better tumor controls and minimum normal tissue toxicity. Harmone suppression and skeletal deformities will remain be the limitations of CSI.

Key Words: Intensity modulated radiotherapy (IMRT), Volumetric Modulated Arc Therapy (VMAT), Craniospinal Irradiation-CSI, Pediatric brain tumor.

A Month in Cross Section: Sphenoid Wing Meningioma’s a Case report of Eleven Case Series, A Single Center Experience

Authors: 1 Aamir Irshad, 1 Shahid Ayub

Institution: 1 Department of Neurosurgery, Hayatabad Medical Complex.

Abstract:

Background: Sphenoid wing meningioma’s are located on the lesser wing of sphenoid encasing anterior clinoid process. They represent 20% of supra-tentorial meningioma’s. Due to higher rate of morbidity, mortality and recurrence which have been documented in comparison to meningioma’s of other locations. In fact, medial sphenoid wing meningioma’s have the highest recurrence rate of all the intracranial meningioma’s. So, proper technical management is required to deal with them because they are quite technical in their management due to the fact that the tumor usually involves the visual pathway, the vasculature located anteriorly and its invasion into cavernous sinus.

Methodology: The authors including lead surgeons operated 11 cases of joint global sphenoid wing meningioma’s in the month of September from 1 st to 30th, 2023. A veritable highest presentation of these tumors in a single month prompted the reporting of early surgical outcomes of these patients. Patient demographic, pre-operative and post-operative clinical, radiological parameters and salient points of interests were noted down. Clinical outcome criteria were included; improvement in visual acuity, neural deficit and headache, extent of resection as noted by the principal surgeon as well as post-operative radiology. Due to limited number of cases and type of tumor, patient survival was the major surgical outcome criterion.

Results: A total of 11 patients age from 28 years to 65 years were included in this study. Among them, Female (09) to Male (02) with ratio of 4.5. Radiologically and preoperatively invasion of cavernous sinus was noted in 04 patients. On clinical examination there was diplopia in 09 patients, proptosis in 05 patients, internal carotid artery involvement in 04 patients. Those patients in which medial sphenoid wing was completely involved with neurovascular structures, post operatively they had visual deterioration. In so far, in these patients the extent of resection was limited and the post-operative morbidity greater.

Three patients in whom the internal carotid was completely encased, and the surgeon opted for GTR, full thickness MCA infarct was noted in 6 hours’ post-operative scan, they were converted to a full 16 cm decompressive craniotomy, one survived with hemiparesis and aphasia and two died (one male (49 years), one female (65 years), both left craniotomy). GTR was attempted in 07 patients among whom three patients had complete carotid encasement. STR was done in four patients all of whom had cavernous sinus invasion and internal carotid encasement. Diplopia improved in seven out of nine, and proptosis resolved completely in the five patients.

Conclusion: Giant sphenoid meningioma’s involving the medial sphenoid wing and associated neurovascular structures represent a surgical challenge and must be treated with caution and STR. If and when GTR is to be attempted, a precaution must be taken of early CT Brain postoperatively to prevent loss of life.

COMPARISON OF SUCCESS RATE OF FRONTAL VERSUS OCCIPITAL ENTRY SITE FOR VENTRICULOPERITONEAL SHUNT

SHUJAT MOMAND UNDER SUPERVISION OF PROF.HAFIZ ABDUL MAJID

Introduction: Hydrocephalus is a common disorder of cerebral spinal ﬂuid (CSF) physiology which may occur because of overproduction, decreased absorption and obstruction of CSF circulation, resulting in abnormal expansion of the cerebral ventricles. Many diversion techniques have been developed including, shunting techniques through ventriculoperitoneal (VP) shunt, ventricular-pleural shunt, and endoscopic third Ventriculostomy (ETV). Despite advancements in shunting technology, complications remain a significant concern. There are some contradictions regarding the effectiveness of proximal catheter entry sites that increase the shunt success rate.

Objectives: The objective of the study is to compare efficacy of the shunt with the ventricular Kocher’s and ventricular Frazier’s entry sites.

Materials and methods: A total of 60 patients fulfilling the inclusion criteria from the Department of Neurosurgery unit III, Punjab Institute of Neuroscience Lahore included in the study after taking the informed consent and permission from the ethical committee. This is a Qausi-experimental study with Non Probability consecutive sampling. Postoperatively shunt malfunction noted during the hospital stay and routine follow-up in OPD up to 6 months, Statistical analysis performed with SPSS latest Version.

Results: The over All Shunt Failure rate Per Year In Patient with Frontal Catheter placement is Low then Occipital One, rate Of Infection was Slightly high in Frontal Entry site but Over drainage And Obstruction was Significantly low In patient with Frontal catheter placement, Catheter placement was Accurate in nearly all Patients with Frontal Entry site while around 15%of Catheter was not accurately placed with Occipital entry site.

Conclusion: The Success rate of Frontal Catheter Placement for VP shunt is High then Occipital one.

Analysis of cerebral Microdialysis in patients with traumatic brain injury: relation to Intracranial Pressure and Cerebral Compliance

Kashif Ali Sultan, Prof Fauzia Sajjad,

Neuro Critical Care Unit, Department of Neurosurgery, Jinnah Hospital Lahore

E-mail: sultankashif11@gmail.com, (+92-300-4131192)

ABSTRACT

Background: Cerebral Microdialysis (CMD) is used to monitor local brain chemistry of patients with traumatic brain injury (TBI). Despite an extensive literature on CMD in the clinical setting, it remains unclear how individual data of real-time CMD is to be interpreted. Intracranial pressure (ICP) and cerebral compliance are important continuous brain monitoring parameters in neurointensive care. They are used as surrogate monitors of cerebral blood flow and have an established relation to outcome. The purpose of this study was to investigate the relationship between CMD values and ICP and/or cerebral compliance in patients with TBI.

Methods: Cerebral MD, ICP and cerebral compliance were monitored in 10 patients with TBI. Data was extensively analyzed, using over 730 samples of complete (4 hourly) CMD data sets (glucose, lactate, pyruvate and glycerol) to seek values of ICP, cerebral compliance and MD that were best correlated. CMD catheter positions were located on computed tomography scans as pericontusional or nonpericontusional. CMD markers were analyzed for correlations with ICP and cerebral compliance using time series regression analysis recognition method.

Results: Despite majority data indicating highly perturbed metabolism, CMD shows correlations to ICP and cerebral compliance. In concurrence, the autocorrelation of CMD is high for all markers significantly correlating with the ICP and cerebral compliance. Even at up to 96 future hours the correlation increases with every passing day and relationship is highest on the 7th day of monitoring. Consequently, 52% to 75% of CMD markers are in concordant with ICP and Compliance. This shows that subsequent rather than the initial values of CMD are more reflective of the physical parameters (ICP and Compliance).

Conclusions: The multitude of highly perturbed local chemistry seen in CMD patients with TBI is correlated to the changes in ICP and Compliance. Although disturbances related to pressure and/or compliance have a dominant influence on CMD levels in patients with TBI other undiscovered factors may also have a role to play.

Key words: Cerebral Micro dialysis, intracranial pressure, Cerebral Compliance, Contusion, Traumatic Brain injury.

CHALLENGES IN ENDOSCOPIC SURGERY OF COLLOID CYST OF 3RD VENTRICLE

Dr. Subhan Shahid, Dr. Talha Abbas, Prof Dr. Abdul Hameed.

ABSTRACT

BACKGROUND:

Historically colloid cyst was operated micro surgically through transcortical, trans ventricular and trans callosal approach. Endoscopic excision of colloid cyst is preferred now a days as there is a paradigm shift towards minimally invasive surgery. The objective of this study is to share our endoscopic experience for excision of Colloid cyst.

MATERIAL AND METHODS.

Total number of 06 patients with different consistencies of colloid cysts were operated from July 2022 to June 2023. 05 patients had associated hydrocephalus and one patient had colloid cyst of posterior half of 3rd ventricle without hydrocephalus. All patients were operated endoscopically. The bur hole was made 08cm above glabella and 05 cm lateral to midline.

RESULTS:

Complete excision of Colloid cyst with capsule was achieved in 04 patients. Intracapsular debulking was achieved in 02 patients. Hydrocephalus resolution was achieved in all patients. 01 patient had small colloid cyst in posterior half of 3rd ventricle for which sub choroidal trans vallum interpositrum approach was adopted. 02 patients had large size cyst and left us with no space between genu of internal capsule and the cyst to reach the foramen of Monroe, so the excision was done through septum pellucidum. Patients in which the cyst had hard consistency for which modified maneuver of suction was adopted.

CONCLUSION:

Endoscopic Trans ventricular removal of colloid cyst poses challenges but for successful accomplishment of procedure one must have sound knowledge of intraventricular anatomy. Colloid cyst when symptomatic should be treated surgically as soon as possible before permanent neurological damage occurs. Endoscopic excision of Colloid cyst is effective way of treatment and gives excellent results when performed carefully.

Outcomes of Minimal Invasive Spine Surgery Trans Peduncular Fixation

Shahzad Hussain Shah1, Muhammad Ishfaque2, Talha Rasheed3.

Professor & Head of Neurosurgery Unit II Punjab Institute of Neurosciences Lahore
Senior Registrar, Neurosurgery Unit II, Punjab Institute of Neurosciences Lahore
Post-Graduate Resident Neurosurgery, Neurosurgery Unit II, Punjab Institute of Neurosciences Lahore

Presenter: Dr.Talha Rasheed.

Abstract:

Introduction: Percutaneous placement of trans pedicle screw in the lumbar and thoracic spine has been increasing rapidly over a wide range of surgical indications gaining popularity with the increase in trend over the world due to best cosmetic results (smaller incision). Percutaneous pedicle screw is a novel technique and requires surgical skills.

Objective: To determine the outcomes of percutaneous transpedicular screw fixation in thoracolumbar spine fractures in terms of cosmesis, hospital stay, postoperative outcome as novel technique.

Study Design: Descriptive case series in Unit II, Department of neurosurgery, PINS Lahore.

Duration of Study: Study was carried out in span of four years from July 2019 to June 2023.

Material & Methods: After approval from hospital ethical committee, 93 patients fulfilling the inclusion criteria (intact patient, no canal compromise on CT, wedge/compression fracture) were enrolled in the study. All patients underwent standard percutaneous trans pedicle screw fixation technique and assessed for postoperative pain, hospital stay and cosmesis. Out of 93 patients, 57 are male and 36 are female, age limits ranging from 16 to 47.

Results: • Percutaneous trans pedicle screw fixation minimizes morbidity with open technique (CSF leak, infection, large surgical incisions).

All fixations were analyzed on post-operative pain
Reduction of visual analogue scale score of back pain was observed.

Mean hospital stay: 1 to 2 days Better cosmesis result.

Conclusion: In current study, we determine the outcomes of percutaneous transpedicular screw fixation in thoracolumbar spine fractures in terms of mean hospital stay and postoperative pain. Total of 93 patients, hospital stay was 1 to 2 days and post-operative pain was found in 15.6% (n=.4). We concluded that the described technique has sufficient pain control.

KEYWORDS: Thoracolumbar spine fracture, Percutaneous transpedicular fixation, post-operative pain.

Ultrasound-activated nano-TiO2loaded with temozolomide paves the way for resection of chemoresistant glioblastoma multiforme

Dr Sajjad Ullah.

Assistant Professor, Department of Neurosurgery

Khyber Teaching Hospital/Khyber Medical college, Peshawar

Contact: +923349095344 (Email: sajjad.kmc@gmail.com).

Introduction:

Glioblastoma multiforme (GBM) is one of the most daunting issues to modern therapeutics, with a higher mortality rate post-diagnosis. Temozolomide (TMZ) is the only available treatment; however, the frequent resistance leaves the oncologists at a dead end. Therefore, new approaches to circumvent the GBM are highly desired. We have employed TiO2nanosticks loaded with TMZ as nanomedicine for TMZ-resistant GBM resection in this contribution.

Results:

The ultrasonication triple-action effect could greatly facilitate tumor ablation by enhancing the TiO2 nanosticks traversing across BBB, releasing the TMZ payload from TiO2 nanosticks and reactive oxygen species (ROS) generation from TiO2 nanosticks within the GBM milieu. The tumor ablation was confirmed by MTT and Annexin(v)-PI assays, apoptotic proteins expression via western blot and ROS level detection in vitro, whereas tumor volume, weight, survival rate, and relative photon flux in the xenograft and orthoptic TMZ-resistant GBM murine models as in vivo.

Conclusion:

We found this nanomedicine-based ultrasound modality highly efficient in GBM treatment and is of future clinical application value due to the employment of already FDA-approved techniques and nanomedicine.

Preservation of Facial nerve function during Cerebellopontine angle surgery: A learners Experience of 10 cases

Author: Dr Ismaeel Khalid Iqbal Designation: Post Graduate Resident, PINS Lahore,

Email: ismaeelkhalid197@gmail.com, Contact: 03326565125

Abstract:

Background: Facial nerve preservation is one of the main goals in Cerebellopontine angle (CPA) tumor Surgery. Surgical procedures in this territory pose a significant risk of impairing the seventh cranial nerve functions with a long postoperative recovery period.Facial paralysis has potentially devastating functional and psychological consequences for the patients. To reduce the risk of facial nerve injury, modern day neurosurgery is being equipped with preoperative imaging, intraoperative monitoring and meticulous surgical techniques of CPA tumor resection.

Objectives: To evaluate the importance of Facial nerve identification preoperatively and accurate resection of CPA tumor with and with neuromonitoring on postoperative facial nerve functions.

Study design: This is a retrospective clinical case series.

Patients and methods: This study was conducted on 10 patients operated upon for various CPA tumors including Vestibular schwannoma (VS)and Meningioma. All had intact facial nerve (House-Brackmann (HB) grade 1) with impaired hearing in patients with VS. MR imaging for all cases to predict the location of Facial nerve was undertaken preoperatively. Intraoperative neuromonitoring was used in 5 cases while intracapsular excision with focused accurate technique was used in all the patients to preserve the facial nerve function. All the patients were followed postoperatively with examination of facial nerve and grading according to HB grading system.

Results: Fortunately, due to all the perioperative cautionary measures and fine, accurate intraoperative dissection all the patients had House-Brackmann grade 1 postoperatively and were able to Smile postoperatively when asked for a photograph. Near total removal was achieved in all patients.

Conclusion: Facial nerve function can be preserved with preoperative planning, intraoperative monitoring and cautious extra-arachnoidal surgical technique with special importance to the seventh cranial nerve.

Keywords: Cerebellopontine angle surgery, Facial Nerve Preservation, Vestibular Schwannoma.

Primary Intracranial Leiomyosarcoma (PICLMS): A Systematic Review of Case Reports and Case Series from 2000 to 2023.

Haseeb Mehmood Qadri, Muhammad Talha Bilal, Aqsa Umar, Muhammad Faraz Khalid Nizami, Jawariah Nazir, Momin Bashir, Sumira Kiran, Asif Bashir

Presenter: Dr. Haseeb Mehmood Qadri

Designation: Post Graduate Resident, Institute: Punjab Institute of Neurosciences, Lahore

Email: haseebmehmood18@yahoo.com, Contact# 03328373574

ABSTRACT:

Background: Leiomyosarcoma is a rare malignancy of the smooth muscle cell, uterus being the most frequently affected organ. Cases involving the CNS primarily without any evidence of systemic disease have emerged, questioning its oncologic origin.

Objective: To determine the epidemiology, clinico-pathological patterns and neuro-oncological management of PICLMS.

Materials and Methods: After an extensive literature search using PubMed Central and Google Scholar, 24 case reports and one case series comprising 36 patients with PICLMS were retrieved and included using the Preferred Reporting Items for Systematic Reviews and Meta- Analyses guidelines, published between 2000 and 2023.

Results: Male preponderance of the neoplasm (55.56%) with the mean age of 43.10 ± 15.37 years was noted. Headache, head mass and motor deficit were the most common presenting manifestations among 17.02%, 13.83% and 11.70% patients, respectively. PICLMS arose from brain parenchyma in 75.03% cases, mostly involving the frontal lobe (19.44%) and left hemisphere (36.11%). Meningeal, venous and bony origins were also seen. Heterogenous mass was noted among 21.79% cases on MRI. Gross Total Resection was possible in 63.89% lesions. A mean follow up of 21.32 ± 22.64 months was noted. Intracranial recurrence was noted in 33.33% patients.

Conclusions: Surgery and adjuvant radiotherapy are the mainstay of treatment of PICLMS, while meningioma an important differential diagnosis. Its highly variable presentation makes MRI an unreliable investigation to diagnose PICLMS pre-operatively. High recurrence rate, combined with aggressive behavior make keen follow up essential. Fruitful chemotherapeutic regimens can only be developed after seeking the oncologic origin of PICLMS.

Keywords: Leiomyosarcoma, intracranial leiomyosacoma, brain smooth muscle tumor.

Primary Intramedullary Lymphoma of Spinal Cord (PILSC): A Systematic Review of Case Reports and Case Series from 2000 to 2023

Presenter: Dr. Haseeb Mehmood Qadri

Designation: Post Graduate Resident, Institute: Punjab Institute of Neurosciences, Lahore. Email: haseebmehmood18@yahoo.com, Contact# 03328373574

ABSTRACT:

Background: Primary CNS lymphoma accounts for three percent of all newly diagnosed CNS tumours and 1-3% of all non-Hodgkin’s lymphomas. The oncologic origin of primary intramedullary lymphoma of the spinal cord (PILSC) is an enigma.

Objectives: To determine the clinical manifestations, disease course and management of PILSC.

Materials and methods: A comprehensive literature search using PubMed Central and Google Scholar, was done, retrieving 17 case reports and two case series of 21 patients with PILSC and included using the Preferred Reporting Items for Systematic Reviews and Meta- Analyses guidelines, published between 2000 and 2023.

Results: About 90.48% patients inflicted with PILSC were adult, with male predominance, 61.90%. The most common complaint at presentation was neurological deficit of motor type in 32.14% patients. MRI proved to be helpful in 76.19% cases, with spinal cord enlargement and high signal intensity in 19.04% cases. Adjuvant chemotherapy and radiotherapy was acquired by 52.38% and 38.09% patients. Non-Hodgkin type was reported in 90.47% cases and Hodgkin lymphoma was seen in 9.52% patients. Diffuse large B cell lymphoma was culprit in 41.10% cases. Five out of 21 cases had variable post-operative complications. The average follow-up was 16.16 months.

Conclusion: PILSC is a multifaceted neoplasm in all its clinico-pathological aspects of presentation. Although rare, PILSC can involve adult and paediatric populations with a clear male preponderance. The MRI findings are not reliable to make a preliminary diagnosis. Like other lymphomas, the role of chemoradiotherapy is clearly more significant than surgical intervention in improving patient prognosis. Histopathologically, it can be Non-Hodgkin or Hodgkin, B-cell type or T-cell type and has a wide array of immunohistochemistry positivity.

Keywords: Spinal lymphoma, Lymphoma of spine, Lymphoma of cord.

MOLECULAR SIGNATURES FOR SURVIVAL PREDICTION IN GLIOMA: A PROSPECTIVE, REAL-WORLD DATA ANALYSIS

Mohammad Hamza Bajwa 3 (Presenting Author), Altaf Ali Laghari 3 , Sufiyan Sufiyan 3 , Sana Naeem 3 , Wajiha Amin 3 , Syed Ather Enam 1,2,3 , Nouman Mughal 3*

Center of Oncological Research in Surgery, The Aga Khan University, Karachi, Pakistan.
Juma Research Laboratory, The Aga Khan University, Karachi, Pakistan
Department of Surgery, The Aga Khan University, Karachi, Pakistan

*Corresponding Author, Preferred Presentation Type: Oral presentation, Category: Neuro-Oncology

Objective: Glioma molecular signatures are underreported from low-and-middle-income country centers within the literature. With the emphasis on molecular markers for survival prediction, there is a need for robust data exploring molecular epidemiology in these countries. We conducted a prospective study of gliomas treated at our center with comprehensive molecular analysis and overall survival after surgery.

Method: 140 consecutive glioma patients were enrolled in this study from 2019 onwards, with follow-ups to collect demographic, surgical, treatment, and survival data. Histopathological and molecular analysis was performed on archived formalin-fixed paraffin-embedded blocks for IDH, P53, ATRX, and Ki-67 immunohistochemical markers. Survival analysis was calculated using the Kaplan-Meier method; hazard ratios are reported through a multivariate Cox regression model.

Result: Rates of gross total resection within high-grade gliomas were 32.4% for grade III and 41.8% for grade IV gliomas. 67.3% and 57.1% of grade IV and grade III Glioma completed standard chemotherapy regimens. Post-operative radiotherapy was completed by 63.6% of grade IV and 54.3% of grade III gliomas. IDH wild type (IDH- WT) gliomas had a significantly worse overall survival (log-rank=0.001), with 2-year survival rates of 64% for IDH mutant and 34% for IDH-WT. Significant survival differences were seen for Ki-67 index (log-rank=0.003, 2-year survival rate: 36% (High), 65% (Low)) and MGMT promotor mutation (log-rank=0.027, 2-year survival rate: 66% (mutation detected), 33% (mutation not detected)). On further subgroup analysis of Temozolomide (TMZ) response, MGMT promotor mutation showed better survival (log- rank=0.043). On multivariate analysis, IDH mutation (HR:8.1, p=0.003), Ki-67 index (HR:0.01, p<0.0001), and recurrent glioma (HR:4.76, p=0.03) were significant predictors of survival.

Conclusion: Our findings highlight significant survival differences among glioma within the region for IDH, Ki-67 index, and MGMT promotor mutations. Although these markers are not commonly used in low-and-middle-income country centers, our results strongly support their greater implementation for prognostication.

Barriers to epilepsy surgery: a questionnaire-based assessment of parents/guardians of children diagnosed with epilepsy in a low- and middle- income country

Mohammad Hamza Bajwa 1 (Presenting Author), Saqib Kamran Bakhshi 1 , Fatima Gauhar 2 , Ayesha Akbar Waheed 2 , Muhammad bin Hammad 2 , Sijal Akhtar 2 , Muhammad bin Nasir 2 , Farhan Arshad Mirza 2 , Syed Ather Enam 1*

Section of Neurosurgery, The Aga Khan University, Karachi, Pakistan. 2. Medical College, The Aga Khan University, Karachi, Pakistan. 3. Department of Neurosurgery, University of Kentucky College of Medicine, Kentucky, USA.

* Corresponding Author: Syed Ather Enam, S.I.

MD, PhD, DABNS, FRCS, Professor of Neurosurgery

The Aga Khan University, Karachi, Pakistan. (ather.enam@aku.edu).

Preferred Presentation Type: Oral presentation.

Abstract:

Introduction: Pakistan has a prevalence of 9.9/1000 for epilepsy, which constitutes approximately 1/10th of the global burden (approximately 2 million people). Approximately 30% of these patients have refractory epilepsy. However, no recent data is available on epilepsy surgery awareness from the region.

Methods: It was a cross-sectional study. Patients diagnosed with epilepsy at our hospital during 2.5 years (July 2018 – December 2020) were retrieved from the Neurophysiology database. After obtaining approval from ethical review committee, these patients were called for data collection on phone. Data was collected from the parents/guardians of patients. Statistical analysis was done using SPSS.

Results: We obtained 194 responses. There were more male patients (119; 61.3%) than females (75; 38.7%). The current median age of patients was 10 years (IQR: 6-14), and the median age at time of first seizure was 3 years (IQR: 0.5 – 7.5). Two-third of the patients were currently seizure free (115; 59.3%), 31 (16%) of them off antiepileptic drugs (AEDs), and the median seizure free period was 1.5 years (IQR: 0.25 – 3). Three quarters of the respondents (144; 74.2%) had never heard about epilepsy surgery. Forty-eight patients (24.8%) reported more than 1 seizure per month, and 29 (60.4%) of these were unaware of the surgical treatment. Sixty-four patients (33%) were taking 3 or more AEDs, and 42 (65.6%) of these had not been counseled about surgical evaluation.

Conclusion: Epilepsy surgery is underutilized. The possible reasons could be under- availability of comprehensive epilepsy surgery programs, reluctance of neurologists to acquire neurosurgical referral and inadequate communication between neurosurgeons and neurologists. Further studies to answer the questions raised by our study and can help formulate future strategy for managing refractory epilepsy patients the country.

Keywords: Epilepsy surgery, low-and-middle-income countries, epidemiology.

Artificial Intelligence in Glioma Management: A Systematic Review of Reviews

Mohammad Hamza Bajwa 2 (Presenting Author), Umar Ahmed Siddiqui 1 , Rabeet Tariq 1 , Aabiya Arif 3 , Yusra Saleem Siddiqui 1 , Zenab Shehzad 1 , Haissan Iftikhar 4 , Saad Akhtar Khan* 1

1 Department of Neurosurgery, Liaquat National Hospital and Medical College, Karachi, Pakistan

2 Department of Neurosurgery, Aga Khan University Hospital, Karachi, Pakistan

3 Ziauddin University, Karachi, Pakistan, 4 University Hospitals, Birmingham, United Kingdom

*Corresponding Author: Preferred Presentation Type: Oral presentation

Category: Neuro-Oncology

Introduction: Artificial intelligence (AI) models are revolutionizing glioma assessment and treatment, with the potential to improve diagnostic accuracy of this heterogeneous disease. This systematic review evaluates existing AI applications for Glioma management.

Methods: We searched PubMed, Scopus and Cochrane Library databases – 812 articles were screened by two authors with conflicts resolved by a third author. 24 unique reviews were identified, categorized into ML (2), non-invasive genomic marker identification (10), prognostication (1), tumor grading/diagnosis (10), and tumor segmentation (1).

Results: Results showed good performance of ML for differentiation from pseudo progression etc., while few moderate quality studies demonstrated utility in survival prediction using molecular markers. Validation is needed before clinical use but emerging themes such as radiomics analysis & 3D spatial resolution suggest promise for predictive & personalized protocols through image extraction & auto segmentation. These AI/ML models could enable comprehensive patient care outcomes through strong correlations between texture analysis & molecular characteristics and offer more accurate diagnosis than imaging alone can provide.

Conclusion: Further research needs to focus on validating these models using real world data sets to ensure they can be confidently incorporated into clinical practice and establish the efficacy of AI in improving glioma management outcomes.

Feasibility and Outcomes of Awake Craniotomy form Brain Arteriovenous Malformations: A Scoping Review

Mohammad Hamza Bajwa, MBBS 1 (Presenting Author); Rabeet Tariq, MBBS 1 ; Umar Ahmed Siddiqui, MBBS 2 ; Ahmer Nasir Baig, MBBS 1 ; Saad Akhtar Khan, MBBS, MRCPS, FCPS, FEBNS, FACS 2 ; Areeba Tariq MBBS 2 , Saqib Kamran Bakhshi MBBS, FCPS 2 .

1 Department of Neurosurgery, Aga Khan University Hospital, Karachi, Pakistan. 2 Department of Neurosurgery, Liaquat National Hospital, and Medical College, Karachi, Pakistan.

Abstract:

Background: Brain Arteriovenous Malformations (AVMs) located in proximity to eloquent brain regions are associated with poor surgical outcomes, which may be due to higher rates of postoperative neurological deterioration. Awake Craniotomy (AC) allows intraoperative mapping of eloquent areas to improve post-operative neurologic outcomes, and may be a viable solution for improving AVM resections.

Methods: Three databases including PubMed, Scopus, and Cochrane Library were searched using a predefined search strategy. After removing duplicates and screening, full texts were analyzed. Outcomes including the extent of resection, intra-operative and post-operative complications, and long-term neurologic outcomes were assessed.

Results: 12 studies were included with a total of 122 AVM cases. Spetzler–Martin grading was used for the classification of the AVMs. The asleep–awake–asleep protocol was most commonly used for AC. Complete resection was achieved in all cases except 5. Intraoperative complications included seizures (n=2) and bleeding (n=4). Short-term post-operative complications included hemorrhage (n=3), neurologic dysfunctions including paresis (n=3), hemiplegia (n=10), dysphasia/aphasia (n=6), cranial nerve dysfunction (n=3), and pulmonary embolism (n=1). Almost all neurological deficits after surgery gradually improved on subsequent follow-ups, and neurologic outcomes were more satisfactory when compared to stereotactic radiosurgery or surgical resection under general anesthesia.

Conclusion: AVMs may shift the anatomical location of eloquent brain areas which may be mapped during AC. AC is a viable approach for AVM resection with better postoperative outcomes compared to surgical resection under GA or SRS. All studies recommended AC for the resection of AVMs in close proximity to eloquent areas.

Awake craniotomy for intra-axial brain tumors does not affect size of residual disease: a systematic review and meta-analysis

Mohammad Hamza Bajwa 1 (Presenting Author), Nowal Hussain 2, Muhammad Waqas Saeed Baqai 1 , Faiza Urooj 1 , Unaiza Naeem 2 , Syed Hasan Shuja 2 , Ali Hyder Nazeer 3 , Ahsan Ali Khan 1 , Syed Ather Enam 1 , Saqib Kamran Bakhshi 1.

Affiliations:

1: Section of Neurosurgery, Department of Surgery, The Aga Khan University, Karachi, Pakistan

2: Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan

3: Medical College, The Aga Khan University, Karachi, Pakistan

 Corresponding Author email: saqib.bakhshi@aku.edu

Abstract:

Background: Awake craniotomy (AC) for intra-axial brain tumors is useful for preserving cortical and subcortical white matter tracts that may have tumor invasion. No specific guideline or concrete evidence exists regarding the superiority of AC over surgery under general anesthesia (GA), with many surgeons preferring resection under GA for benefits of potentially better extent of resection.

Methods: A systematic review and meta-analysis was conducted in accordance with PRISMA guidelines and registered on PROSPERO (CRD42022311131). A comprehensive search was conducted using specific keywords and MeSH terms with Boolean operators, from PubMED and Cochrane databases. Pooled effect size was estimated using a Mantel-Haenszel random-effects model, with evaluation of heterogeneity using Higgins I 2 statistic.

Results: Of 929 articles, ten were included for quantitative analysis. Selected studies included 1974 patients (681 in the AC group, 1293 in the GA group). No significant differences were seen between GA and AC groups in terms of extent of resection (MD: 3.77, p=0.38, I2=91%), rates of gross total resection (OR: 1.20, p=0.69, I2=74%), OR time (MD: 5.96, p=0.15, I2=0%), or length of stay (MD: -3.39, p=0.21, I2=92%).

Conclusion: AC is not inferior to surgery under GA for extent of resection of intra-axial brain tumors, with comparable rates of GTR and EOR. While non-significant, current data trends towards shorter operating time and length of stay as well for AC group patients. Though we could not perform quantitative comparison of neurological outcomes due to non-availability of comparative data, the available evidence did not support one technique over the other.

Keywords: awake craniotomy, meta-analysis, neuro-oncology.

HISTOPATHOLOGICAL DIAGNOSIS AND SURGICAL OUTCOME OF TUMORS OF THE SPINAL CORD

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Corresponding Author: -Muhammad Muizz Uddin,(muhammadmuizzuddin0@gmail.com)

Huda Raja, Zulqarnain Anis, Uzair Yaqoob

Department of Neurosurgery, Dow University of Health Sciences Karachi, Civil Hospital Karachi.

OBJECTIVE: – To determine the histopathology, their frequencies and surgical outcome tumors of spinal cord.

METHODS: – This retrospective investigation sought to assess the surgical outcomes associated with spinal cord tumors. The research was conducted at the Department of Neurosurgery within the Shaheed Mohtarma Benazir Bhutto Institute of Trauma Center, spanning comprehensive four-year duration from 2020 to July 2023.

RESULT: – The study comprised 37 participants with a mean age of 31.43±10.56(standard deviation) . Among the participants, 25 (67.6%) were males and 12 (32.4%) were females. Notably, Schwanoma of spinal cord constituted 29.7% (11/37) of all cases, with dorsal spine tumors accounting for encompassing 25 (67.6%) out of 37 cases. When the outcomes were followed, no new neurological deficit was observed in any case and 33/37 (89.18%). Moreover, four out of the total had improvement in their neurological powers.

CONCLUSION: – Overall, the study's analysis of tumor characteristics, surgical outcomes, and anatomical distributions enriches our understanding of spinal cord tumors and their management. The results not only contribute to the existing body of knowledge but also offer clinicians valuable insights to guide personalized treatment approaches and optimize patient outcomes in the challenging realm of spinal cord tumor management. As medical understanding continues to evolve, these findings serve as a significant step forward in the pursuit of enhancing patient care and advancing our knowledge of spinal cord tumor dynamics.

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Joyous walking in Potts’ disease “Hit the nail on the Head” via anterior cage fixation

Dr. Zaid sami ullah

post-graduate resident neurosurgery

AIMC/ JINNAH HOSPITAL LAHORE.

ABSTRACT

Historically, anterior decompression via costotransversectomy or direct posterior decompression and fixation has been the surgical management of choice in spinal tuberculosis. With time, there is an evolving technique of anterior approach and fixation using a titanium cage filled with bony grafts for tuberculosis in the adult thoracic spine. This study aimed to review the safety and efficacy of this treatment.

METHODS: 15 adult thoracic tuberculosis patients were identified where an anterior approach and cage fixation were performed. These were all midthoracic TB as circumferential surgery is still favoured in thoracolumbar disease. The surgery was performed by a single surgical team at a tertiary hospital. A retrospective review of clinical notes and radiological studies was performed.

RESULTS: The majority of patients had two vertebral bodies involved and required an average of four-body fusion. Out of 15 patients 1 presented with pain and improved clinically after surgery. 4 patients presented with paraplegia out of which 1 patient improved neurologically with a power of 3/5 in the right leg and 2/5 in the left leg, remaining 3 patients are on our follow-up in which power has not improved. Out of 15 patients, 10 presented with paraparesis in which 7 patients started walking at 3-6 month intervals and the remaining 3 patients' power also improved and hopefully, they will also start walking in future follow-up visits.

CONCLUSION: Transthoracic anterior body fixation provides an effective treatment modality for thoracic Potts disease. There is a high success rate in achieving a return to ambulatory status with few complications.

Keywords: Spine, tuberculosis, anterior, surgery, adult.

Outcome of Spinal Dysraphism surgery without Electrophysiological Monitoring in a resource-constrained country: Our 10 years institutional Experience

Dr. Sana Jamal, Dr. Usman Ahmad Kamboh, Prof. Fauzia Sajjad, Department of Neurosurgery, AIMC/Jinnah Hospital Lahore.

Abstract:

Background: Spinal dysraphism is the failure of the fusion of midline structures of the spine. They are divided into two categories (a) spina bifida aperta /open type and (b) spina bifida occulta /closed type. Electrophysiological studies are highly valuable for evaluating preoperative and postoperative patients. Motor-evoked potentials (MEPs) and somatosensory-evoked potentials (SSEPs) are commonly practiced tools. Intraoperative Neurophysiological monitoring can obviate complications. Our setup has a resource constraint, so we did the spinal dysraphism surgery without electrophysiological studies

Objective: Our study aims to establish the efficacy of spinal dysraphism surgery without electrophysiological studies in a resource-constrained country to improve pediatric neurosurgery skills.

Materials and Methods: It is a retrospective study conducted from July, 2013 to June, 2023 in Department of Neurosurgery, AIMC/Jinnah Hospital Lahore. Data was collected on a designed proforma and data regarding symptoms, location, variety, neuro-rehabilitation and surgical technique was collected. Data was analysed for the outcome. A total of 250 patients were analyzed.

Results: A total of 250 patients were analyzed. Out of these 65 patients presented with swelling, 135 with cutaneous stigmata and 50 with neurological deficits. Spinal dysraphism mostly located in the lumbosacral region (63%), there is no case documented in the cervical region. Spina bifida cystica i.e. meningocele without hydrocephalus has more prevalence (29.6%) than meningocele with hydrocephalus. Among spina bifida occulta Lipomyelomeningocele is in the highest ratio (21.6%). In our study, the excision of spinal dysraphism was performed in 160 patients, 20 patients had detethering of the cord and 60 patients had reconstructive surgery. 76 % of patients had static outcomes despite of lack of electrophysiological monitoring, 17% of patients showed improvement in the neurological deficit and 7% of patients get deteriorated. We have an in-home reconstructive surgery speciality available and our total of 60 patients underwent this facility after multidisciplinary team discussion.

Conclusion: The outcome remained same in our setup despite the lack of electrophysiological monitoring as compared to other setups having good electrophysiological monitoring. It is reasonably justifiable to do spinal dysraphism surgery in resource constraint countries even without monitoring. Further research is guaranteed because the current IONM methodology in spinal dysraphism is still deficient in the quantitative and objective evaluation and fails to directly measure the sacral autonomic nervous system.

Key words: Spinal Dysraphism, Motor-evoked potentials (MEPs), somatosensory-evoked potentials (SSEPs), meningocele, Lipomyelomeningocele, IONM (intraoperative neurophysiological monitoring).

Impact of depression and anxiety on survival, quality of life and overall morbidity in adult brain tumour patients: A systematic review

Fahad Zahid 1,3, Meher Angez 2 , Mohammad Shahmeer Chaudhry 2 , Iqra Fatima 2 , Ali Azan Ahmed 2 , Mohammad Hamza Bajwa 1,3 , Nida Zahid 3 , Altaf Ali Laghari 1,3 , Ehsan Bari 1,3 , Syed Ather Enam 1,3 , Ahsan Ali Khan 1,3*

Affiliation:

Section of Neurosurgery, Aga Khan University, Karachi, Pakistan
Medical College, Aga Khan University, Karachi, Pakistan
Department of Surgery, Aga Khan University, Karachi, Pakistan

Dr. Fahad Zahid, (Aga Khan University), Email: Fahad.zahid22@alumni.aku.edu

Abstract:

Background: Depression and anxiety have a significant effect on the morbidity and survival of patients suffering from brain tumors. The objective of this review is to define and quantify adverse outcomes associated with depression and anxiety in adult brain tumor patients.

Methods: Our study is designed as a systematic review. Articles from databases of PubMed (MEDLINE) and the Cochrane Library were systematically extracted using a search string on 21 st December 2021. Data was extracted, and their quality assessed by three reviewers. The protocol was registered on Prospero with the registration number as follow. CRD42022299266.

Results: A total of 1229 articles were identified in the original search and 42 articles were included in the final review. Presence of depression or higher degree of depressive symptoms was associated with a decreased survival in 9 out of 10 studies; worse quality of life in 21 out of 23 studies; lower physical functioning in 8 out of 10 studies; poor cognitive functioning in 8 out of 13 studies. Presence of anxiety or higher degree of anxiousness was associated with a decreased survival in 2 out of 3 studies, associated with a poor quality of life in 8 out of 9 studies, with worse physical functioning in 2 out of 3 studies and with poor cognitive functioning in 4 out of 8 studies.

Conclusion: Our paper identifies that a strong correlation exists between depression and anxiety and patient morbidity and mortality with depression showing a much stronger correlation as compared to anxiety. We recommend that screening for depressive and anxiety disorders should be part of multi-modal management of brain tumor patients.

Keywords: depression, anxiety, outcomes.

Endovascular Thrombectomy Versus Medical Management in Patients with Acute Ischemic Stroke with Large Infarct: A Systematic Review and Meta- Analysis of Randomized Controlled Trials

CONSIDERATION: ANY. Either ORAL or POSTER PRESENTATION

Authors: Danisha Kumar, MBBS 1 ; Aman Goyal, MBBS 2 ; Nirmit Patel, MD 3

Affiliations:

Dow University of Health Sciences, Baba-e-Urdu Road, Karachi, Pakistan
Department of Internal Medicine, Seth GS Medical College and KEM Hospital, Mumbai, India-400012
Department of Cardiology Research, AMA School of Medicine, Makati, Philippines

Presenter/ Corresponding Author: Danisha Kumar, MBBS, Affiliation: Dow University of Health Sciences, Baba-e-Urdu Road, Karachi, Pakistan, Email: dhirani20090@gmail.com, (Phone: +923313011671)

ABSTRACT:

Introduction: Endovascular treatment (EVT) is used for patients with ischemic stroke.The criteria for selecting patients for EVT involves ASPECTS of 6 or higher, small to medium-sized areas of damage, or a mismatch between the condition and perfusion imaging within 6-24 hours. Our study aims to compare the efficacy of EVT to medical therapy (MT) for this group of patients.

Methods: A search was independently carried out on PubMed, Embase, and Clinicaltrial.gov, from inception until August 20th, 2023. Two-arm meta-analysis was conducted using the Dersimonian and Laird random-effects model. Outcomes were reported as pooled OR along with 95% CI. Statistical significance was determined if the 95% CI did not cross the value of "1", and the two-tailed P-value was less than 0.05. Statistical analyses were performed with STATA 17.

Results: 3 RCTS with 1010 patients (509 in EVT group and 501 in the MT group) were included. EVT was associated with a significantly higher rate of achieving a mRS score of 0-2 (OR = 2.53, 95% CI: 1.76-3.64, p < 0.001) and mRS 0-3 (OR = 1.75, 95% CI: 1.28-2.39, p < 0.001). EVT group had a significantly increased risk of any intracranial hemorrhage (OR =2.34, 95% CI: 1.53-3.58, p > 0.001). However, the risk of 90-day mortality, hemi-craniotomy , and adverse cardiovascular events were comparable between the EVT and MT groups.

Conclusion: In conclusion, patients with large infarcts had better functional outcomes when treated with EVT than with MT alone. However, the incidence of intracranial hemorrhage was higher in the EVT group.

Keywords: Ischemic stroke, Endovascular thrombectomy, Large infarct

Modified Rankin Scale 0-2, B. Modified Rankin Scale 0-3, C. Intracranial hemorrhage, D. Symptomatic intracranial hemorrhage, E. 90 Days mortality, F. Adverse cardiovascular event, Figure 1. Forest plot of primary and secondary outcomes.

THE RELATIONSHIP BETWEEN MECHANISM OF TRAUMA AND PRESENCE OF ACUTE SUBDURAL HEMATOMA

Corresponding Author: -Muhammad Muizz Uddin

(muhammadmuizzuddin0@gmail.com)

Zulqarnian, Muhammad Mohsin, Umair Sharif And Aithesham

Department of Neurosurgery, Dow University of Health Sciences Karachi, Civil

Hospital Karachi

Objective:

To determine the association between the mechanism of trauma and the occurrence of Acute Subdural Hematoma (ASDH) in patients.

Methodology:

A retrospective study done at Shaheed Mohtarma Benazir Bhutto Institute of Trauma, located at Civil Hospital Karachi, Pakistan. The data for this study is collected from medical records covering a period of two years, from January 2021 to January 2023. Considering a desired level of precision and an anticipated prevalence of subdural hematoma, a sample size of 168 participants was included

Result:

The statistical analysis was done which shows that participants with age more than 35 years have higher incidence of ASDH and they are involved in high velocity trauma. The younger patients have incidence of other traumatic brain injuries but overall 117 out of 168 had ASDH which is very significant and shows a stronger relationship with high velocity trauma. And 100 out 117 had trauma on high speed roads.

Conclusion: –

Through investigating the relationship between the mechanism of trauma and ASDH occurrence, severity, and clinical outcomes, the proposed study aims to contribute to the existing knowledge on the management and prognosis of patients with traumatic brain injuries, specifically focusing on ASDH. The findings of this study have the potential to inform clinical practices, enhance risk stratification, and improve patient outcomes in the context of traumatic brain injuries.

A Multi-disciplinary Approach towards Management of Huge Cranio- Cervical Region Tumors

Zubair Ahmed Khan 1, Noor ul ain, Prof. Hafiz Abdul Majid

1 Punjab Institute of Neurosciences, Lahore, Pakistan.

Abstract:

Background:

Cranio-cervical region includes head and neck which comprise of many vascular, soft tissue and bony structures. Huge size tumourous lesions rarely arise in cranio-cervical region and usually are highly aggressive, <1% occurrence in literature. Though infrequently reported, the clinical outcome of such lesions after surgery is still not fully determined. A multi-disciplinary approach toward these tumors can help in reducing recurrence rate and better outcome.

Methodology:

This study includes the retrospective review of 5 patients with huge cranial and cervical lesions treated in one year. A multidisciplinary approach involving different disciplines was implied. The goal was to achieve tumor-free margins upto safe limit and preservation of cosmesis and function while keeping in view the cost-effectiveness of procedure.

Results:

This Study included 5 patients with a median age of 30 years. The median follow-up duration was 6 months. The average lesion size was 12×8 cm. 4/5 (80%) lesions were present in head and 1/5 (20%) was in neck region. Gross total excision was done in all tumors along with tumor free margins. Biopsy of Cranial lesions showed dermatofibrosarcoma Protuberans, osteosarcoma, glioblastoma multiforme and metastatic tumor while in cervical was neurofibrosarcoma. Plastic surgery, pathology and oncology departments were involved in management and followup of these patients.

Conclusion:

A multidisciplinary approach is mandatory in management of huge cranio-cervical region tumors for better surgical cosmetic outcome.

Key Words: Cranio-cervical, tumors, multidisciplinary.

OBESITY! AN INDEPENDENT PREDICTOR OF POOR OSWESTSRY DISABILITY INDEX (ODI) AND DUBIOUS OPERATIVE BENEFITS IN SURGICAL LOW BACK PAIN? A PROSPECTIVE SINGLE CENTRE COHORT ANALYSIS

Muhammad Osama 1, Muhammad Adil Khatri 1 , Farhad Ali 1 , Muhammad Sameer 1 , Irfan Ali Shah 1 , Atiq Ahmed Khan 1 , Muhammad Imran 1 .

Background: A substantial proportion of patients with low back pain are categorized as obese, And obesity contributes to disability associated with LBP. Various methods have been devised to calibrate the disability index associated with low back pain. One of the most validated ones is Oswestry Disability Index. A higher disability index is associated with poor post-operative outcomes, lesser degree of patient satisfaction, prolonged length of hospital stay and increased cost to the health care system. The primary outcome of this study was to compare the ODI score between obese and non-obese patients with low back pain undergoing decompression +/- fixation procedure. While the secondary outcome was to compare the pre and post-operative ODI score in obese patients.

Methods: After ERC approval and informed consent, A single centre blinded prospective cohort study enrolling 50 patients aged 18-70 years with low back pain diagnosed as spinal canal stenosis, prolapsed intervertebral disc or degenerative spondylolisthesis planned for decompression +/- fixation procedure presenting to Neurosurgery department SMBB Institute of trauma was conducted from Jan, 2022 till Dec, 2022. The examined factors included the patients’ demographics, co-morbidities, BMI and pre and post-operative ODI score which was assessed at three months follow-up of surgical intervention. BMI > 30 was considered as obese.

Results: The mean age of the patients’ enrolled was 42.3 +/- 10.5 years, with 54% being males. 26% of the patients had 3 or more co-morbidities. 22(44%) of the patients had BMI >30 and were categorized as obese. The mean pre-operative ODI score was 43%, with most patients falling in 21-40% category. After matching for confounding variables between the obese vs. non-obese patients’ group, no significant difference was found between the age (p=0.37) and co-morbidities (p=0.16). There was a statistically significant difference between the ODI score of obese vs non-obese patients. (54% vs 29% respectively, p=0.03). 45% of the patients in the obese group were found in the category of having ODI score of 41-60%, while 60% of patients in the non-obese group had ODI score of 21- 40%. There was reduction in the mean post-operative ODI score at three months among obese patients from 54% to 41%, however this was not statistically significant (p=0.06). In contrast, there was statistically significant difference in the mean pre and post-operative ODI score among non-obese patients. (29% preoperative vs 13% post-operative, p=0.03).

Conclusion: ODI score remains a precise predictor of disability among patients with LBP undergoing operative intervention. Considering the above-mentioned findings, obesity seems to be an inadvertent factor in contributing to disability. There has been a considerable reduction in the ODI index in both obese and non-obese patients following surgical intervention, thus obesity should not be used as an indicator to preclude operative intervention.

Keywords: Obesity, disability, Oswestry disability index (ODI), post-operative ODI score.

Retrospective Study of Endoscopic Endonasal Transphenoidal Approach to the Skull Base at Hayatabad Medical Complex, Peshawar

Muhammad Yasir Basir 1, Attaurrehman 2 , Muhammad Shafique 2 , Abbas Qadir 2

1,2 Department of Neurosurgery, Hayatabad Medical Complex, Peshawar, KPK, Pakistan.

Corresponding Author, (Dr Muhammad Yasir Basir)

Resident Neurosurgeon, Hayatabad Medical Complex Peshawar, KPK, Pakistan

Email: ys.basir@gmail.com

Presentation: oral.

ABSTRACT

Objectives: The study aimed to ascertain the clinical outcome and complications of endoscopic endonasal transsphenoidal surgery (ETSS) for Sellar Lesions and CSF Leaks. Material & Methods: A retrospective study conducted at the Department of Neurosurgery Hayatabad Medical Complex Peshawar, Pakistan. The various lesions like pituitary adenomas and craniopharyngiomas were operated and findings documented. The final diagnosis was based on radiological investigations, hormonal profiles, per op findings and histopathology. The patients of CSF leak secondary to trauma, idiopathic and iatrogenic were also included. Post-surgical outcomes were documented.

Results: Out of 103 patients, 57% were male, and 43% female patients. The mean age was 41 ± 5 years. Headache was reported in 63% as a most common presentation, followed by decreased visual acuity in 51 %, amenorrhea in 19%, and acromegaly in 31% of patients. Overall, the symptoms related to surgical improvement were observed in 81% of patients. A good surgical outcome was observed in 77% of patients. The visual acuity was improved in the patients presented within 3-6 months of deterioration of vision. The most common complication was the transient diabetes insipidus in 33%, Meningitis in 5%, Cerebrospinal fluid (CSF) leak in 3% and hematoma in 0.5% patients. The CSF leak was treated by duraplasty and duraseal endoscopically. Most of the symptomatic patients showed improvement.

Conclusion: Endoscopic endonasal transsphenoidal surgery (ETSS) is a safe, less invasive, cosmetically effective approach to the skull base. There was significant decrease in morbidity, mortality, and hospital stay.

Keywords: Endoscopic Endonasal Transsphenoidal Surgery (ETSS), Pituitary adenoma, CSF Leak.

Underutilization of epilepsy surgery in Pakistan: Ten-year experience from the only Comprehensive Epilepsy Center in the country

Saqib Kamran Bakhshi, Rabeet Tariq, Usman Khalid, Saman Hamid, Namra Qadeer, Farhan Arshad Mirza, Syed Ather Enam.

Introduction:

Eighty percent of the global epilepsy burden is borne by developing countries, and 30% of these patients have drug-resistant epilepsy (DRE). Epilepsy surgery (ES) can significantly improve the cognition and quality of life in DRE. A comprehensive epilepsy center was established in Pakistan in 2010, the only facility for ES in a country of 231 million people. Hundreds of epilepsy patients are medically managed at the center each year.

Objective:

We aimed to study seizure control in all ES cases performed at the only comprehensive epilepsy center in the country during last ten years.

Methods:

It was a retrospective cohort study. Medical records of all cases of ES performed at our center from 2012 to 2021 were retrieved, through the Hospital’s Information Management System. Patients were also contacted via phone calls where needed, to collect information about their seizure control as per Engel Classification. Data was analyzed using SPSSv21.

Results:

Thirty-three surgeries including 10 temporal lobectomies with amygdalohippocampectomy, 11 selective amygdalohippocampectomies, 9 corpus callosotomies, 1 callosotomy with lesionectomy, 1 lesionectomy and 1 temporal lobectomy were performed. The median age of patients was 23 (IQR: 18 – 31) years. Complex partial seizures were most common (14; 42.4%), followed by generalized seizures (10; 30.3%). The median duration of AEDs before surgery was 6 (IQR: 3.25 – 13.75) years. Eighteen (54.5%) patients had complete freedom from disabling seizures (Engel Class IA) at a median follow-up of 3.25 (IQR: 1.12 – 6) years. All patients continued to receive antiepileptic drugs after surgery, and all procedures had nearly 50% optimum seizure control outcomes.

Conclusion:

The clinical outcomes of ES performed at our center are consistent with evidence. However, the small volume highlights the underutilization of this extremely important service. More studies are needed to identify the factors responsible for this disparity, so that all DRE patients have access to ES.

National survey of knowledge and practice of neurologists about epilepsy surgery

Saqib Kamran Bakhshi, Rabeet Tariq, Fatima Gauhar, Ayesha Akbar Waheed, Muhammad bin Hammad, Sijal Akhtar, Muhammad bin Nasir, Farhan Arshad Mirza, Muhammad Wasay, Syed Ather Enam.

Introduction:

The efficacy and safety of epilepsy surgery (ES) for refractory epilepsy is well-established. However, despite carrying 1/10th of the global epilepsy burden in Pakistan (approximately 2 million patients), epilepsy surgery is almost non-existent in the world’s fifth most populous country. Apart from the extremely small number of trained epilepsy surgeons, an important factor can be lack of knowledge among neurologists who are the predominant care-givers for epilepsy patients.

Objective:

We aimed to assess the existing knowledge and practices of neurologists in Pakistan about ES to identify gaps in awareness.

Methods:

It was a cross-sectional study. The questionnaire was sent via email and text messages to all the adult and pediatric neurologists in the country via Pakistan Society of Neurology. The response rate was 31.6% (56/177 neurologists). The results were analyzed using SPSSv21.

Results 6 10.7:

Thirty-four neurologists (60.7%) were aware of the correct criteria for medically refractory epilepsy (MRE). Half of the respondents (28; 50%) believed that MRE patients with generalized seizures would not benefit from ES. Twenty neurologists (35.7%) thought that mental retardation was a contraindication to ES. While most neurologist agreed that ES is underutilized in the country (54; 96.4%), and concurred with the need for establishing comprehensive epilepsy treatment centers in the country, only 6 (10.8%) mentioned that they routinely discuss the option of ES with their MRE patients. Seventeen (30.4%) thought that ES has a very low rate of meaningful seizure control. Most of the neurologists were locally board certified (44; 78.6%), followed by US Board certification 6 (10.7%).

Conclusion:

Most neurologists in Pakistan understand the need for improving access to ES, however, they rarely take the surgeon onboard for MRE. The important knowledge gaps identified through our results maybe a reason, in addition to the lack of availability of trained epilepsy surgeons.

Epilepsy and low-grade glioma: seizure control after surgical resection - a retrospective cohort study

Saqib Kamran Bakhshi, Rabeet Tariq, Faiza Urooj, Safwan Masood, Farhan Arshad Mirza, Syed Ather Enam.

Introduction:

Seizures are a common manifestation in patients with low grade glioma (60-75%), and 60 – 90% patients attain seizure freedom after resection. Seizure control varies with histopathology, extent of resection and type of seizures. There is inconsistency in literature regarding utility of anti- epileptic drugs (AED) after tumor resection.

Objective:

We aimed to determine factors associated with seizure control in patients after low grade Glioma (LGG) resection.

Methods:

It was a retrospective cohort study. Medical record of all patients who underwent LGG resection at our center from 2019 to 2021 were reviewed; 77 patients fulfilled the selection criteria. Patients were also contacted via phone calls to collect information about their seizure control as per Engel Classification. Data was analyzed using SPSSv21.

Results:

The mean age was 34.9  11.3 years, and there was male predominance (62; 80.5%). Generalized seizures were the most common type (54; 70%), and Levetiracetam was the most commonly prescribed AED (60; 77.9%). The median duration of pre-operative AED use was 4 (IQR: 1 – 24) months. Frontal lobe was the most common location of tumor (36; 46.8%). Most of the patients had their surgery under general anesthesia (51; 61.4%), while 29 (37.7%) underwent awake craniotomy. Nearly half of the patients had a gross total resection (31; 40.3%), and another 15 (19.5%) had near-total resection. Sixteen patients (20.8%) had their AEDs stopped within first 6 months post-operatively (at variable intervals), and all of them had Engel Class IA to ID control at time of follow-up (p = 0.008). The 12 patients with Grade I glioma also had optimum seizure control (p = 0.032).

Conclusion:

Patients with grade I glioma have better seizure control after surgery. Tumor biopsy is associated with worse seizure outcome, though not statistically significant. Larger studies are needed to determine the ideal time and patient group for discontinuing AED after surgery.

HISTOPATHOLOGICAL DIAGNOSIS AND SURGICAL OUTCOME OF TUMORS OF THE SPINAL CORD

Muhammad Muizz Uddin, Huda Raja, Zulqarnain Anis, Uzair Yaqoob

Dow University of Health Sciences Karachi, Civil Hospital Karachi.

OBJECTIVE: –

To determine the histopathology, their frequencies and surgical outcome tumors of spinal cord.

METHODS: –

This retrospective investigation sought to assess the surgical outcomes associated with spinal cord tumors. The research was conducted at the Department of Neurosurgery within the Shaheed Mohtarma Benazir Bhutto Institute of Trauma Center, spanning comprehensive four-year duration from 2020 to July 2023.

RESULT: –

The study comprised 37 participants with a mean age of 31.43±10.56(standard deviation) . Among the participants, 25 (67.6%) were males and 12 (32.4%) were females. Notably, Schwanoma of spinal cord constituted 29.7% (11/37) of all cases, with dorsal spine tumors accounting for encompassing 25 (67.6%) out of 37 cases. When the outcomes were followed, no new neurological deficit was observed in any case and 33/37 (89.18%). Moreover, four out of the total had improvement in their neurological powers.

CONCLUSION: –

Overall, the study’s analysis of tumor characteristics, surgical outcomes, and anatomical distributions enriches our understanding of spinal cord tumors and their management. The results not only contribute to the existing body of knowledge but also offer clinicians valuable insights to guide personalized treatment approaches and optimize patient outcomes in the challenging realm of spinal cord tumor management. As medical understanding continues to evolve, these findings serve as a significant step forward in the pursuit of enhancing patient care and advancing our knowledge of spinal cord tumor dynamics.

Primary Intracranial Alveolar Soft Part Sarcoma in a 22-Year-Old Female: A Rare Case Report with Literature Review

Muhammad Saad Babar, Haseeb Mehmood Qadri, Ammara Tabassam, Muhammad Imran, Muhammad Hassan Raza.

Submission for: Poster Presentation

Presenter: Dr. Haseeb Mehmood Qadri, Designation: Post Graduate Resident

Institute: Punjab Institute of Neurosciences, Lahore, Email: haseebmehmood18@yahoo.com, Contact# 03328373574

Abstract:

Alveolar soft part sarcoma is a very rare malignant neoplasm of peripheral muscular, adipose or neural tissue. Its occurrence, as a primary intracranial tumour, is even rarer. To the best of our knowledge, only nine cases of primary intracranial alveolar soft part sarcoma exist in English scientific literature. We attempt to write a comprehensive review on this poorly understood intracranial malignancy, with no evident systemic lesions, such as in the case of our 22 years old patient. In addition to absent definitive proof of benefit of radiologic or chemotherapeutic management, we highlight the role of surgery as the primary treatment. Younger patients with this tumour may have a worse prognosis than elderly patients.

Keywords:

Alveolar soft part sarcoma, intracranial, headache, radiosurgery.

Primary Intracranial Alveolar Soft Part Sarcoma (PIASPS): A Systematic Review of Case Reports and Case Series from 2000 – 2023

Haseeb Mehmood Qadri, Hasan Saeed, Awais Ahmad, Ali Raza, Tariq Imran Khokhar, Asif Bashir, Muhammad Imran.

Submission for: Oral Presentation

Presenter: Dr. Haseeb Mehmood Qadri, Designation: Post Graduate Resident

Institute: Punjab Institute of Neurosciences, Lahore. Email: haseebmehmood18@yahoo.com, Contact# 03328373574

ABSTRACT

Background: Alveolar soft part sarcoma is a rare malignancy of the lower extremities considered to be of unknown cellular origin. Common in young female patients, the ASPS usually has a strong metastatic potential, mostly involving the lungs at the time of presentation. Cases involving the CNS primarily, without any evidence of systemic disease have emerged i.e. the primary intracranial alveolar soft part sarcoma (PIASPS).

Objective: To determine the clinical manifestations, natural progression and management of primary intracranial alveolar soft part sarcoma.

Materials and methods: After an extensive literature search using PubMed Central and Google Scholar, seven case reports and two case series of 14 patients with PIASPS were retrieved and included using the Preferred Reporting Items for Systemic review and Meta-analyses guidelines, published between 2000 and 2023.

Results: Female preponderance of the neoplasm (57.14%) with an average age of 24.9 years was noted. Headache (36.36%) and papilledema (25%) were the most common presenting complaint and sign, respectively. Brain parenchymal involvement was noted in 71.42% cases, mostly the frontal lobe and left hemisphere. The lesion appeared isointense to hypointense on T1-weighted images and hyperintense on T2-weighted images (66.67%) on MRI. Gross Total Resection was possible in 57.14% lesions. On immunohistochemistry, the tumor cells manifested TFE3 and PAS positivity in 25% and 20% of the cases respectively. An average survival after follow up duration was found to be 31.79 months.

Conclusion: Surgery and radiotherapy are the mainstay of treatment of PIASPS, while meningioma an important differential diagnosis. TFE3 fusion product is readily been helpful in diagnosis. Evidence of a primary lesion in the CNS cannot rule out the presence of an occult primary elsewhere in the body. This, along with the slow growing nature of the neoplasm and delayed localized recurrences, require a long-term follow-up.

Keywords: Soft part sarcoma, alveolar sarcoma, intracranial soft part sarcoma.

Primary Intracranial Congenital Glioblastoma (PICG): A Systematic Review of Case Reports from 2000 to 2023

Submission for: Poster Presentation, Presenter: Dr. Ahtesham Khizar

Senior Registrar, Institute: Punjab Institute of Neurosciences, Lahore

Email: arwain.6n2@gmail.com, Contact# 03228095862

ABSTRACT

Background: The most commonly reported congenital intracranial space occupying lesions are teratoma, glioma and neuroblastoma. Primary intracranial congenital glioblastoma (PICG) is one of the most lethal and extremely rare neoplasms. Most pediatricians and gynecologists are unable to detect it congenitally, posing an ominous risk of spread and disease severity.

Objective: To determine the clinical manifestations, number of reported cases, radiological findings and neuro-oncological management of PICG.

Materials and Methods: A comprehensive literature search using PubMed Central and Google Scholar was done, retrieving 17 case reports and five case series of 31 patients with PICG and included using the Preferred Reporting items for Systematic Reviews and Meta-Analyses guidelines, published between 2000 and 2023.

Results: The mean age at presentation was 86.00 ± 88.36 days, with both genders affected equally, i.e. 45.16%. The most common symptoms and signs at presentation were seizures (38.70%) and hydrocephalus (51.61%), respectively. Left hemispheric (48.38%), with frontoparietal involvement (16.12%) was the frequently affected site. MRI findings were suggestive of low intensity signal significant of hemorrhage or calcification and a heterogenous mass in 35.58% and 32.25% cases, respectively. Gross total resection (GTR) was achievable in 48.38% patients. Glial fibrillary acid protein and vimentin were positive in 45.16% and 29.03% cases, respectively. Intraoperative mortality and recurrence were noted in 25.80% and 9.68% of patients, respectively. The average follow up duration was 20.57 months.

Conclusion: PICG has an extremely aggressive course of natural progression. Congenital presentation and its lack of awareness among clinicians is itself a challenge for disease management. Adjuvant chemo-radiotherapy has proven fruitful along with GTR. Post-operative CSF diversion is warranted.

Key words: Congenital neoplasm, Glioblastoma, Pediatric neoplasm.

Primary Intramedullary Pilomyxoid Astrocytoma of Spinal Cord (PIPASC): A Systematic Review of Case Reports and Case Series of Two Decades

Haseeb Mehmood Qadri, Muhammad Awais Ahmad, Hasan Saeed, Farah Ismail, Laiba Afzal, Tariq Imran Khokhar, Asif Bashir.

Submission for: Oral Presentation, Dr. Haseeb Mehmood Qadri, Post Graduate Resident

Punjab Institute of Neurosciences, Lahore, Email: haseebmehmood18@yahoo.com

Contact# 03328373574

ABSTRACT

Background: Pilomyxoid Astrocytoma (PMA), new variant of pilocytic astrocytoma, is more aggressive and relatively rare, mostly seen in children and commonly found in brain. Primary intramedullary pilomyxoid astrocytoma of spinal cord (PIPASC) is extremely rare. The distinct aggressive and pathological behavior, poor prognosis and the diversity in response to various treatment modalities makes the PIPASC an oncologic enigma.

Objectives: To evaluate the clinical manifestations, histopathologic spectrum and onco-surgical management of this neoplasm.

Materials and Methods: After an extensive literature search using PubMed Central and Google Scholar, eight case reports and one case series of patients with spinal PA were retrieved and included using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines without applying any filter of time, study type or place. Case presentations of 12 patients were analyzed in this review.

Results: Pediatric preponderance of the neoplasm (75%) with the mean age of 7.90 ± 4.51 years was noted. Sensory deficits and scoliotic deformity were the most common presenting symptom and sign in 83.33% and 33.33% of patients, respectively. Thoracic spine (50%) was most commonly affected region. MRI showed the most consistent findings of cord compression in 100% cases and the lesion appeared hypointense on T1- weighted images (T1WI) and hyperintense on T2-weighted images (33.33%). The average post treatment survival duration was found to be more than 2 years.

Conclusions: Occurrence of PIPASC among pediatric population is rare. They have possibility of extraneural metastasis, can differentiate into more malignant glioma and get recurrent due to which they require a long-term follow-up of the patients. Further studies are required to investigate the utility of chemotherapy and radiotherapy in its management.

Keywords: Spinal astrocytoma, pilomyxoid astrocytoma, astrocytoma of cord.

IMPACT OF OBESITY ON LUMBAR DISC HERNIATION

Dr Murtaza Ahmed (PGR Neurosurgery from SIR Ganga Ram Hospital Lahore)

Abstract:

Background: The patients with lumbar disc herniation present the most in the outpatient department of neurosurgery. There are multiple etiologies behind disc herniation including smoking, weight lifting, straining, life style and obesity. Purpose The purpose of our study was to see the association and impact of lumbar disc herniation with obesity. The impact of obesity on different musculoskeletal system has significant importance but the link between lumbar disc herniation and obesity have been discussed with scarcity.

Method: This study was conducted in the department of neurosurgery at Sir Ganga Ram Hospital/ Fatima Jinnah Medical University (SGRH/ FJMU) during December, 2021 to November, 2022. Total 604 patients were participated in the study. 368 patients were males and 236 were females (N=604; Males=368 Females =236). From a prospective registry, patients undergoing unilateral fenestration and discectomy, bilateral partial laminectomy and discectomy, and endoscopic discectomy were identified with complete BMI data. BMI from 18- 25 was normal while BMI>25 was defined over weight, BMI>30 as obese. Intergroup comparisons across age, gender, and BMI were carried out. We conducted regression analysis to assess the influence of BMI and LDH.

Results: Out of 604 patients, 417 patients were managed conservatively which were assessed on VAS (visual analogue score) and Sciatica Bothersomeness Index (SBI). Among them 87 patients (20.8%)patients were of normal weight, 145(34.77%) were overweight and 185(44.36%) were obese. Whereas the patients which were managed surgically were 187. Among them 74 (39.5%) underwent unilateral fenestration and discectomy, 113 (60.4%) underwent bilateral partial laminectomy and discectomy whereas 16 patients (8.5%) underwent endoscopic discectomy. LDH was more frequent in obese and overweight than in normal-weight patients. Similarly it was observed that obese and overweight patients had more severity of pain as compared to normal patients. Higher the BMI more the excruciating pain and more the neurology was affected and there was seen increasing trend of numbness and radiculopathy.

Conclusions: Most of the patients undergoing surgeries for lumbar disc herniation fell into the category of overweight and obese. Obese patients also had a multilevel disc herniation as compared to the normal patients. Hence obesity may have a robust impact on lumbar disc herniation apart from other pathologies involved.

Keywords: BMI Bilateral partial laminectomy. Endoscopic Lumbar discectomy Lumbar disc herniation · Overweight · Obesity. Unilateral fenestration and discectomy.

Radiofrequency rhizotomy for trigeminal neuralgia with modified approach to foramen ovale.

Dr. Salman Falak, Dr.Talha Abbas (AP-NS), Prof Dr. Abdul Hameed (HOD and Dean of Neurosciences)

ABSTRACT

BACKGROUND:

Radiofrequency rhizotomy (RFR) is a well-established treatment for refractory trigeminal neuralgia. The advantage of RFR over the percutaneous procedures is that it provides the chance of selective rhizotomy over an awake patient and less chances of chemical meningitis. Objective of this study is to discuss early experience of 25 patients who underwent RFR at our setup.

MATERIAL AND METHODS:

Total number of 25 patients underwent RFR. Patients with previous unsuccessful MVD or glycerol rhizotomy, the patients who were not fit for general anesthesia and the patients who did not want to get MVD done were included in this study. Patients with atypical facial pain and not having any trigger zone and with bleeding diasthesis were excluded. Foramen ovale was negotiated with the help of AP view on the C arm fluoroscope. Pain was assessed through VAS pre and post op. All patients were checked for muscles of mastications and corneal reflexes before and after procedure. The end result of treatment was elimination of pain and numbness in the territory of affected nerve root.

RESULTS:

Radiofrequency rhizotomy of 25 patients was performed. 15 were males and 10 were females. 16 patients had TGN of the right side while 9 had on left side. 10 patients had TGN in V2 distribution, 09 patients had V3 involvement whereas 06 patients had V2 and V3 involvement. Pain was effectively relieved in 23 patients except one who had previous glycerol rhizotomy.

CONCLUSION:

In selected patients radiofrequency rhizotomy gives excellent pain control with less procedural complications.

Experience of short-same segment fixation in Thoracolumbar spine traumatic fractures at tertiary care hospital

Dr Burhan Ul Haq 1, Dr Shahzad Ahmed Qasmi 2, Dr Abdul Rehman Arshad3,

1 Registrar Neurosurgery, Department of Neurosurgery, Combined Military Hospital, Lahore, Abdur Rehman Road Lahore, Pakistan. Email burhanulhaq366@gmail.com

2 Classified Neuro- and Spine surgeon, Department of Neurosurgery, Combined Military Hospital, Lahore ,Abdur Rehman Road Lahore ,Pakistan

3 House Surgeon Neurosurgery, Department of Neurosurgery , Combined Military Hospital, Lahore, ,Abdur Rehman Road Lahore ,Pakistan

Abstract

Background: Thoracolumbar (TL) fractures occur when the vertebra is subjected to a significant axial and flexion force vector that brings the failure of the anterior vertebral body in compression. The surgical strategy chosen should correct segmental kyphotic deformity and prevent late instability and pain while permitting early ambulation and return to function. Different surgical techniques have been described. Whilst traditionally it was believed that short segment fixation should be reserved for young active patients, it has become the operative technique of choice for thoracolumbar fractures in all age groups due to it being patient friendly, easier to perform, and having equally good clinical results.

Objective: A prospective study to evaluate the clinical efficacy of including the fractured vertebra in the short segment fixation of the thoracolumbar fractures(TL).

Methodology: A total of 60 patients with TL injuries were admitted at the Combined Military Hospital Lahore between August 2022 and July 2023, of which 25 were selected for this prospective study who were managed by short segment posterior fixation with screws included at the level of fracture. The patient’s functional status was assessed for by American Spinal Injury Association (ASIA) impairment scale. All patients were assessed on follow up , for incidence of reoperation, loss of kyphosis correction (with mean preop and post-op kyphotic angle) , long-term functional status and pain , with radiographs TL Spine in AP and Lateral views.

Results: Short-segments TL fixation was done on 25 patients of which 18 were males and 7 were females. Mean age of the patients was 30. Patients were monitored until 12 months of follow-up. Only one patient (4%) required re-operation due to implant failure or pseudoarthrosis. Mean pre-op kyphosis was 12º, while post-op kyphosis was 10º and follow-up mean kyphosis was 9º. At initial one month follow up, ODI disability score was 21. At average most recent follow-up of 4 months , ODI score was 18. Four patients lost to long-term follow-up.

Conclusions: Short segment fixation in TL Spine fractures is more efficacious with lesser blood loss, fewer complications , cost effectiveness, lesser hospital stay, early mobilization and confers more biomechanical stability to the TL spine with significant reduction is overall disability and pain.

Keywords: Short Same Segment Posterior Fixation, Thoracolumbar fractures.

Complications of Lateral Mass Screw Fixation with Cervical Decompression in Sub-Axial Cervical Spine in Cervical Spondylotic Myelopathy

Dr Burhan Ul Haq 1, Dr Shahzad Ahmed Qasmi 2, Dr Abdul Rehman Arshad3

1 Registrar Neurosurgery, Department of Neurosurgery, Combined Military Hospital, Lahore, Abdur Rehman Road Lahore, Pakistan. Email burhanulhaq366@gmail.com

2 Classified Neuro- and Spine surgeon, Department of Neurosurgery, Combined Military Hospital, Lahore, Abdur Rehman Road Lahore, Pakistan

3 House Surgeon Neurosurgery, Department of Neurosurgery, Combined Military Hospital, Lahore ,Abdur Rehman Road Lahore ,Pakistan

Abstract

Background: Ever since its inception by Roy-Camille in 1979, Lateral mas screw (LMS) fixation has been a widely used surgical technique for fixation of cervical spine, however there is a paucity of available literature determining the complications associated with the technique.

Objective: This study is aimed at determining the surgical challenges and the complications encountered perioperatively and on follow-up of the cases of sub-axial cervical operated upon with LMS fixation.

Methodology: A total of 47 patients with sub-axial cervical spondylotic myelopathy (CSM) were admitted at the Combined Military Hospital Lahore between August 2022 and July 2023, of which 18 were selected for this prospective study who were operated upon with LMS fixation and laminectomy and were assessed on a six monthly follow-up. All patients underwent cervical spine radiographs in Anteroposterior (AP), Lateral and dynamic flexion-extension views, along with CT scan and MRI Cervical Spine pre-operatively. The patient’s preoperative, post-operative and follow-up neurological functional status was assessed for by nurick score. All patients were assessed for resolution of symptoms, surgical site wound/scar, cervical spine biomechanical stability and myelopathy severity respectively, on follow up cervical radiographs alongside neck disability index (NDI) score, and nurick myelopathy score, respectively at one, three and six months’ follow-up.

Results: A total of 18 patients underwent LMS fixation with decompression, of which 11 were males and 7 were females. Mean age of the patients was 63. Patients were monitored until 12 months of follow-up,with interval follow-ups at 1,3,6 till 12 months. At initial one month follow up, NDI disability score was 27. At average most recent follow-up of 4 months, NDI score was 18. Mean pre-operative nurick score was 5. Mean post- operative nurick score at 6 month follow up was 3, suggesting improvement in the symptoms of CSM. A total of 4 patients lost to long-term follow-up. There were no cases of spinal cord or vertebral artery injury, or adjacent segment disease. No cases were reported to have had intra-operative dural tears. One patient developed post-operative cenral cord syndrome. One patient had widespread arachnoiditis with OPLL, who developed post-operative meningitis and died on 18 th post-operative day, besides neurological improvement was observed. One patient developed peri-operative spontaneous subarachnoid hemorrhage, manifesting as generalized tonic-clonic seizures post-extubation and died at sixth post-operative day. Two patients developed surgical site infection. No patients had post-operative CSF leaks or CSF fistula. All patients had radiographic union, and no patient developed mechanical implant failure requiring removal of instrumentation.

Conclusion: Lateral mass screw fixation is an effective surgical approach for the management of CSM, with significant reduction in disability and good biomechanical stability of neck. There are lesser chances of complications related to the neural and vascular injuries. With the pre-existing OPLL (ossified posterior longitudinal ligament), complication rate was high due to longer operative times.

ENDOSCOPIC RESECTION OF SUPRASELLAR ARACHNOID CYST

SANAULLAH, PROF. RIAZ A RAJA

ABSTRACT

BACKGROUND:

Surgical management of Suprasellar arachnoid cyst include endoscopic. fenestration, cysto-peritoneal shunt and craniotomy with excision and fenestration. Aim of our study is determine outcome of endoscopic resection of Suprasellar Arachnoid cyst in terms of extent of resection, clinical improvement and peri-operative complications.

MATERIAL AND METHODS:

In this Case series endoscopic resection of Suprasellar Arachnoid cyst was done in 6 patients at Department of Neurosurgery, Liaquat university hospital Hyderabad, from Jan 2020 to July 2022. Procedure was considered as successful when patient shows clinical improvement up to 1 month post-operatively.

RESULTS:

In this case series 6 patients were included. 2 patients (33.33) were male and 4 (66.66) were female. Out of 6 patients sub-total excision was achieved in 4 patients (66.66) and fenestration was done in 2 patients (33.33). Clinical improvement occurred in 5 patients (83.33) out of 6 patients and VP shunt was done in remaining 1 patient who did not show clinical improvement. 3 patients had fever and 1 patient developed fits post-operatively.

CONCLUSION:

Endoscopic resection of Supra Sellar Arachnoid cyst is safe, effective and feasible procedure. Significant Extent of resection is possible by endoscopic approach with less peri-operative complications. Endoscopic resection of Supra sellar Arachnoid cyst should be considered as preferred procedure over other techniques.

KEYWORDS:

Endoscopic resection, excision, fenestraion of suprasellar archnoid cyst, Neuroendoscopy.

SURGICAL OUTCOME OF PATIENTS WITH MALIGNANT MCA INFARCT

AUTHORS: • Dr Mahrukh Afreen – PG Y IV Neurosurgery, Shifa International Hospital, Islamabad. mahrukh.afreen@gmail.com

Dr M. Nadeem – HOD Neurosurgery, Shifa International Hospital, Islamabad. neuronadeem1@yahoo.com
Dr S. M. Vaqar Hussain – Assistant Consultant Neurosurgery, Shifa International Hospital, Islamabad. vaqar_hussain@hotmail.com

INTRODUCTION: Malignant MCA stroke causes cerebral edema leading to deterioration in GCS from brain herniation causing mortality. Timely performed large decompressive hemicraniectomy (DHC) of the respective side is a lifesaving procedure for such patients. The purpose of this study is to evaluate the effectiveness of DHC in treatment of malignant MCA infarct.

METHOD: A retrospective 5 years (February 2018 – 2023) observational, cross-sectional study was done in Shifa International Hospital, Islamabad, department of neurosurgery; of patients of either age and gender with full thickness MCA infarct were included. Patients with deteriorating GCS with mass effect and signs of raised ICP underwent DHC. DHC done for any other reason such as trauma or posterior fossa infarcts were excluded. Change in GCS and mRS at arrival, discharge and at 6 months within hospital mortality and 6-month mortality was recorded of enrolled patients to assess the functional status.

RESULTS: 56 patients fulfilled our inclusion criteria; 18 males and 38 females having mean age of 53.26 +/-12.52 years. 58.92% had right while 41.07% had left MCA infarct. mRS at arrival and 6 months was 2.50 +/- 0.8 and 3.91+/- 1.1 respectively. GCS at arrival, discharge and at 6 months was 9.08 +/- 2.12, 11.2 +/- 3.8 and 11.91+/-3.8 respectively. 5 patients and 11 patients had in-hospital mortality and then mortality at 6 months respectively. 11 patients underwent tracheostomy and 6 patients had PEG tube placement. Better mRS score at arrival showed lower in-hospital mortality (p value 0.05) while prolonged hospital stay decreased in-hospital mortality (p-value 0.045). Patients having tracheostomy and PEG tube had better mRS scores at 6 months (p-value 0.018 and 0.021 respectively). Better GCS at time of DHC had better mRS at 6 months follow up (p-value=0.07). Patients undergoing early DC had better outcome at 6 months (p-value=0.042)

CONCLUSION: Early DHC in patients with malignant MCA infarct is a lifesaving procedure with improved functional status and decreased mortality.

KEYWORD: Malignant stroke, full thickness infarct, decompressive hemicraniectomy.

Frequency and clinicoradiological characteristics of traumatic thoracolumbar fractures: An institute-based experience

Dr.Shabih Ayeshah, Resident Neurosurgery, Department of Neurosurgery, Civil Hospital/Dow University of Health Sciences, Karachi, Pakistan, Email address: sayeshayk@gmail.com

ABSTRACT

Introduction: Thoracolumbar fractures are the most common type of injuries seen in the emergency department in patients with spinal trauma. The global incidence of spinal fractures due to trauma is estimated to be 10.5 per 100,000 cases with the prevalence of thoracolumbar fractures estimated to be 22.96%. This study aims to determine the frequency, demographics and clinicoradiological characteristics of patients with traumatic thoracolumbar fractures presenting to a level I trauma center in Karachi.

Methods: A retrospective study was conducted at Shaheed Mohtarma Benazir Bhutto Institute of Trauma, Karachi involving reviewing of medical records of patients with traumatic thoracolumbar spine fractures from 1 st January 2022 till 31 st December 2022. The demographic characteristics, neurological status, type, and level of fractures were analyzed using the thoracolumbar AO spine injury score (TLAOSIS), McAfee classification, and the American Spinal Cord Injury Association (ASIA) Impairment Scale.

Results: A total of 318 patients presented to the trauma center with traumatic thoracolumbar fractures during the study period with an incidence of 1.35 per 100,000. The mean age of the patients was 36.91±9.4 years. The majority of the patients were males (66%) with road traffic accidents as the most common mechanism of injury in 60.4% of the patients. 56.6% of the patients had a burst type (McAfee) of fracture with L1 (30.2%) being the most common site of fracture followed by D12 (20.8%) vertebrae. 7.6% of the patients had fractures at 2 levels. The neurological status in a significant number of patients was B (43.4%) based on the ASIA impairment scale. Type A fractures (TLAOSIS) were most common with 40.3% of patients having an A3 type of fracture.

Conclusion: There is sparse data available on traumatic thoracolumbar fractures from our population. The results will help in developing a basis for future studies, add to the epidemiological data on the subject and help in developing strategies to minimize the frequency of traumatic thoracolumbar fractures and in the long run decrease the socioeconomic burden.

Keywords: Spine, Thoracolumbar spine fractures, ASIA impairment scale.

Epidemiological Insights and Surgical Considerations for Skull Base Meningiomas: A Retrospective Analysis Using the ABC Surgical Score

Dr.Shabih Ayeshah, Resident Neurosurgery, Department of Neurosurgery, Civil Hospital/Dow University of Health Sciences, Karachi, Pakistan. Email: sayeshayk@gmail.com

ABSTRACT

Introduction: Skull base meningiomas, although relatively uncommon, pose significant challenges due to their intricate location and potential impact on critical neurological structures. Within our specific population, there exists a notable scarcity of comprehensive data pertaining to this complex medical condition. ABC surgical score is a new scoring system of skull base meningioma use to estimate extent of excision preoperatively and predict the possible neurological outcome following surgery, it is comprised of 5 factors and can be calculated on the basis of preoperative imaging analysis.

Methods: A single center retrospective cohort study (Jan 2020 – Dec 2022) encompassing the patients diagnose with skull base meningioma was undertaken at the Shaheed Mohtarma Benazir Bhutto Institute of Trauma Karachi. The investigation focused on multiple aspects including demographics, reported outcomes and components of ABC surgical score including neurological condition, tumor characteristics such as type and size of attachment, extent of artery involvement, proximity to the brain stem, tumor location, cranial nerve engagement.

Results: The medical record of 32 patients diagnose with skull base meningioma at the center were analysed. Mean age was 31.68 years +/- 14.56 years and 69% were females. The most prevalent type was olfactory groove meningioma, 12.5% of patients had an "Attachment Size" of less than 2 cm and 56% of the patients had involvement of multiple arteries. Concerning anatomical details, 63% of participants lacked a visible cerebrospinal fluid space, followed by 50% of cases situated within the central cavity. Regarding nerve involvement half of the cases had involvement of two or more cranial nerves, while the middle fossa was the most commonly affected location (40%). Tumors with attachment of 2-4 cm tumor had the highest morbidity (n=10) and mortality (n=6). Tumors involving multiple arteries also had unfavorable outcome (n=6) in comparison to single artery involvement.

Conclusion: The components of the ABC score lays the framework preoperatively to assess the efficacy of the operative outcome, these components being highly predictive of the unfavorable outcomes helps guide the surgeon as well as the patients to anticipate the debilitating neurological sequela, thus being an extremely effective tool in decision making, however multiple prospective large center trials are needed to validate the sensitivity and specificity of this score.

Key words: ABC surgical risk score, skull base, meningioma.

Hemostatic Effect of Permissive Hypotension Along with Adrenaline Mixed Saline Irrigation in Neurosurgical Procedures: A Series of 1000 Cases

Gohar Ali 1, Zubair Ahmad Khan 1, Mubashir Malik 2 , Prof Hafiz Abdul Majid 1, 1 Punjab Institute of Neurosciences Lahore. 2 Masood Hospital Lahore.

Abstract:

Introduction: With advancement and transformation in neurosurgery, maximum safe surgery and improved surgical outcome has a very important role. Hemostasis during the surgical procedure is a vital element which improves the outcome and helps to achieve the desire goal of surgery. Different methods have been adapted to attain the above said goal. Use of permissive hypotension and adrenaline mixed saline irrigation are one of the techniques to gain minimal blood loss, clean surgical field and excision of tumors without any major complications during the surgery.

Objective: To assess the hemostatic effect of permissive hypotension along with adrenaline mixed saline irrigation in neurosurgical procedure.

Material and method: This was a quasi-experimental study conducted at Punjab Institute of Neurosciences and Masood Hospital Lahore. In this series 1000 neurosurgical cases were operated from May 2022 to May 2023.

Results: Age range of the patients was from 06 months to 70 years. Males were 47% and Females were 53%. Out of total 1000 cases 100(10%) cases were of endoscopic endo-nasal excision of sellar suprasellar lesions, 50(05%) were endoscopic endo-nasal CSF Rhinorrhea repair, 750(75%) cases of supra-tentorial craniotomies including 227(30.2%) Glioma, 273(36.4%) Meningioma, 218(29.06%) sellar/suprasellar lesions, 30(4%) cerebral abscess, 02(0.2%) avm, 50(05%) infra-tentorial craniotomy and 48(4.8%) spinal tumors, 02(.02%) pediatric suturectomies. Following variables were assessed; Intraoperative blood loss i.e. cranial surgeries <200 ml, spinal surgeries <100 ml, post-operative drain <50 ml in 24 hours and post- operative wound site hematoma was NIL in all cases. Average hospital stay was 24 hours to 48 hours in all cases.

Conclusion: Use of permissible hypotension and adrenaline mixed saline irrigation are one of the techniques to gain minimal blood loss, clean surgical field and excision of tumors without any major complications during the surgery. It also decreases the total surgery and anesthesia time, lesser hospital stay, prevents the attendants from the stress of blood arrangement, a possible blood reaction and also benefit for Jehovah’s witnesses.

Hinge Craniotomy: An Alternative to Decompressive Craniectomy in Traumatic Brain Injury

Muhammad Usman

Department of Neurosurgery, PAF Hospital, Fazaia Medical College, Islamabad.

ABSTRACT:

Introduction: Decompressive craniectomy for relieve of cerebral edema and optimizing intracranial pressure is a well-established practice but is prone to complications and requires second surgery (cranioplasty). Hinge craniotomy on the other hand is a technique that serves the same purpose and obviates the need for second surgery.

Methods: This comparative cross-sectional study was conducted at the Neurosurgery department of PAF Hospital, Islamabad from September 2022 to June 2023. Patients underwent surgery either decompressive craniectomy (DC) or hinge craniotomy (HC) were studied. The clinical outcomes of both groups were studied with a minimum follow-up of 3 months.

Results: Majority of the patients in both groups were males and the most common age group was 20-40 years. There was no statistically significant difference between the clinical outcomes of two groups, but DC is related with prolong treatment, increase re-admission rate and complications related to DC and cranioplasty.

Conclusion: Hinge craniotomy could be considered as an effective alternative to decompressive craniectomy for traumatic brain injury in selected case, because of its less complication rate and no need for second surgery. However, further larger studies are required in the form of randomized controlled trials in our setup for generalization of the results.

Keywords: Hinge craniotomy, Decompressive craniectomy, Clinical outcome, Traumatic brain injury.

___________________________________________________________________

Corresponding Author:

Dr. Muhammad Usman, Associate Professor, Department of Neurosurgery, PAF

Hospital, Fazaia Medical College, Islamabad – Pakistan.

Email: drusman387@yahoo.com.

OUTCOME FOLLOWING DECOMPRESSIVE CRANIECTOMY IN MODERATE AND SEVERE HEAD INJURY PATIENTS: A 5-YEAR SINGLE-CENTRE EXPERIENCE WITH FOLLOW UP

Prof.Dr.Ashraf Mehmood, RMU, Rawalpindi.

ABSTRACT:

BACKGROUND: The role of decompressive craniectomy (DC) as a treatment option for moderate and severe head injury, although debatable, has become more common at our tertiary care hospital. Keeping this in view, this study was conducted to evaluate this practice (DC) with special focus on functional outcome.

OBJECTIVE: This study aims at observing functional outcome of moderate and severe head injury patients who underwent decompressive craniectomy for raised intracranial pressure (ICP).

METHODS: This study was a prospective cohort study carried out at Holy Family Hospital, Rawalpindi. The research was conducted over a 5-year period (January 2018 to December 2022). Head injury patients of both genders with ages 20 to 70 years, glasgow coma score at the time of injury, time between injury and decompressive craniectomy and indications of decompressive craniectomy were included in the research. Long term functional outcome of decompressive craniectomy was assessed at 1 and 3 months post- surgery using glasgow outcome scale. The data was analysed using IBM statistics SPSS version 20.

RESULTS: Forty patients underwent DC for raised and refractory ICP. Out of 40, majority (32) were males and minority (8) were females. 20 (50%) patients belonged to the age group of 25-45 years. Glasgow Outcome Scale (GOS) at discharge, 1-month and 3-month follow-up were reported. GOS at 3-month follow-up showed 7 patients (25%) patients had a good recovery, moderate disability was reported in 5 patients (22.2%), and severe disability in 4 patients (16.7%), persistent vegetative state was seen in 5 patients (6.9%). 20 patients had in hospital mortality (50.0%).

CONCLUSIONS: DC is associated with an in hospital mortality of 50.0%. Favourable outcomes were seen in 51.4% patients. The results are comparable to international literature.

KEYWORDS: Decompressive craniectomy, traumatic brain injury, glasgow coma score, severe head injury, glasgow outcome scale, intracranial pressure.

Comparative Analysis of Interbody Spacers Versus Tricortical Graft with Anterior Plate Fixation for Anterior Cervical Discectomy and fusion in Degenerative Cervical Disc Disease

Dr Abdul Aziz,Dr Ehtisham ,Dr Shahbaz ,Dr Haider,Dr Khalid zadran ,Dr kamal ,Dr Deen M,Dr Atiya ,Dr Aqsa, (Abbottabad).

ABSTRACT:

Objectives:

To compare autologous tricortical iliac crest bone graft with locked anterior cervical plate with interbody spacer.

Materials and Methods:

This prospective study was conducted in the Department of Neurosurgery, Ayub teaching hospital from January 2019 to may 2020. Only those patients having prolapsed intervertebral cervical discs or cervical stenosis were included while those with multiple level involvement, trauma, fracture and previously operated patients for any cervical pathology were excluded. Pre-op and postoperative data were documented. For all patients, tricortical iliac bone autograft and rigid plate instrumentation was used to optimize fusion, cervical collar was not used post op.

Results:

Total 60 patients fulfilled the inclusion criteria and enrolled in the study. Patients were divided into two groups, Group A included 30 patients who under tricortical graft while Group B also had 30 patients who received spacer. The age range was from 20 to 55 with a mean age — years ± 2.5.The C5 – C6 was the commonest site for fusion in our study. Odam’s clinic-radiological criteria for functional assessment after cervical discectomy and fusion was used. In 90% (29 each ) patients of ACDF with tricortical group & spacer group was having excellent to good result .One patient in each group had poor results due to persistent radiculopathy and neck pain.

Conclusion:

The ACDF with the tricortical iliac bone autograft and mini plate application is the choice treatment in appropriately selected patients. It increases chances of fusion and abates the need for post op cervical collar. There is some risk of adjacent level disease but high cost of artificial disc replacement renders it unaffordable for our patients.

Key Words:

Cervical radiculopathy, ACDF, Miniplate, Outcome. Iliac bone graft. Abbreviations: ACDF: Anterior Cervical Discectomy and Fusion. VAS: Visual Analogue Score.

Incidence of Postoperative Diabetes Insipidus after Pituitary Surgery and factors leading to this complication

Dr Abdul Aziz, Dr Ehtisham, Dr Baynazir, Dr Gul M, Dr idrees, Dr waseem, Dr Meena, Dr Nisar, Dr raffia (Abbottabad)

Background:

Determining risk factors for diabetes insipidus (DI) after pituitary surgery is important in improving patient care. Our objective is to determine the incidence and factors associated with DI after pituitary surgery.

Methods:

This study was conducted in the department of neurosurgery Ayub teaching hospital from September 2015 to January 2021. Patients with preoperative DI were excluded.

Results:

A total of 130 patients were included. The incidence of postoperative DI was 27.8%. Percent change in serum Na (odds ratio [OR], 1.39; 95% confidence interval [CI], 1.15 to 1.69); preoperative serum Na (OR, 1.19; 95% CI, 1.02 to 1.40); and performance of craniotomy (OR, 5.48; 95% CI, 1.60 to 18.80) remained significantly associated with an increased incidence of postoperative DI, meningioma on histopathology significantly associated with a decreased incidence.

Conclusion

Greater percent change in serum Na, preoperative serum Na, and performance of craniotomy significantly increased the likelihood of postoperative DI while meningioma on histopathology was significantly associated with a decreased incidence.

Keywords:

Diabetes insipidus, Vasopressins, Neurosurgery, Postoperative complications, Neuro –endocrinology.

Carotid Endarterectomy: Our Experience at Brain Surgery Hospital

Arif Malik¹, Muhammad AmmadUl Haq², Saad Javed³

Brain Surgery Hospital, Rawalpindi; arifpsn@gmail.com

Senior registrar, Holy Family Hospital, Rawalpindi Medical University, Rawalpindi, Pakistan; ammad86@gmail.com

Registrar, Department of Neurosurgery, Holy Family Hospital, Rawalpindi Medical University, Rawalpindi, Pakistan; saad.javed@rmur.edu.pk

Background: Carotid artery stenosis is a major risk factor for ischemic stroke. Carotid endarterectomy (CEA) remains the gold standard treatment for severe stenosis, aiming to prevent future strokes. CEA involves surgical removal of atherosclerotic plaque buildup from the Internal Carotid Artery and carotid bifurcation. Literature demonstrates the benefit of CEA over medical therapy alone for both stroke prevention and mortality reduction in certain patients. As a result, current guidelines endorse CEA for symptomatic patients with 70-99% stenosis and for asymptomatic patients with 60-99% stenosis, in appropriate surgical candidates. Patient selection focusing on age, comorbidities, and surgical risk is imperative. With accumulating evidence supporting CEA and advances in perioperative care, CEA volumes have increased over the past decade. However, contemporary real-world outcomes remain unclear. This retrospective study examines our single academic institution’s recent experience with CEA over the past 10 years. We aimed to evaluate indication, patient selection, procedural techniques, complication rates, and short and long-term outcomes following CEA at our center.

Methods: We retrospectively reviewed the medical records of consecutive patients undergoing CEA at Brain Surgery Hospital between January 1, 2013 and December 31, 2022. Data was collected through our institutional database and individual chart review. Information gathered included baseline demographics such as age, gender, and comorbidities, procedural details including symptom status, degree of stenosis, surgical approach, anesthesia type, and operative duration; hospital length of stay; and perioperative outcomes including stroke, death, myocardial infarction, cranial nerve injury, hematoma, and other complications occurring within 30 days of surgery. Patients were followed up to ascertain any delayed complications, reinterventions, or adverse events related to CEA.

Results: Among the 10 patients who underwent Carotid Endarterectomy for treatment of high-grade stenosis on Carotid Doppler Study, the mean age was approximately 58 years with 80% males. All patients having Transient Ischemic Attacks (TIA) with greater than 70% occlusion on Carotid Doppler were included in the study. All patients underwent Carotid Endarterectomy without stenting. All the surgeries were done under General Anesthesia. The mean duration of surgery was approximately 73 minutes. Comorbidity analysis revealed that hypertension was prevalent in 6 patients, diabetes in 3, and hyperlipidemia in 4. There were no recorded instances of postoperative mortality, intraoperative complications, or postoperative complications. The mean length of stay was 3 days.

Conclusions: In this single-center review of 10 cases over 12 years, our perioperative outcomesare consistent with the guidelines for carotid endarterectomy. This real-world data validates that carotid endarterectomy remains a safe and effective treatment option for patients with severe carotid stenosis. Meticulous preoperative screening and evaluation by a multidisciplinary team enabled optimal patient selection at our center. Further research on integrating emerging predictors of poor outcomes into individualized patient selection is warranted to optimize the risk-benefit ratio of CEA. Additional studies directly comparing contemporary results of CEA and carotid artery stenting would also inform decision-making. In conclusion, within an experienced center, carotid endarterectomy should remain in the armamentarium for stroke prevention in appropriate candidates with severe carotid stenosis.

The 36th Annual Conference
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ABSTRACTS

Results:

Conclusion:

Abstract

Background:

Methods:

This study was conducted in the department of neurosurgery Ayub teaching hospital from September 2015 to January 2021. Patients with preoperative DI were excluded.

Results:

Conclusion

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ABSTRACTS

Results:

Conclusion:

Abstract

Background:

Methods:

This study was conducted in the department of neurosurgery Ayub teaching hospital from September 2015 to January 2021. Patients with preoperative DI were excluded.

Results:

Conclusion

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The 36th Annual Conference
PAKISTAN SOCIETY OF NEUROSURGEONS