Neurology India
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Clinical Trial
Role of emergency surgery to reduce mortality from rebleed in patients with aneurysmal SAH.
Potentially salvageable patients with aneurysmal subarachnoid hemorrhage may rebleed and die after admission to a hospital, awaiting an angiogram or surgery. In an attempt to reduce the number of patients thus lost, we are operating on such patients on an emergency basis. This report is a retrospective analysis of patients operated early after aneurysmal SAH, but during routine working hours, versus patients operated on an emergency basis. ⋯ Angiographic vasospasm was associated with poor out come, in either group, in grade IV patients. Patients in Grades I to III should undergo emergency surgery, if the surgeon is experienced and willing to operate at odd hours and necessary support facilities of neuroradiology and neuroanaesthesiology are available. This would avoid deaths in patients awaiting angiograms or surgery.
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Two uncommon cases of unilateral, asymmetrical hydrocephalus secondary to membranous occlusion of foramen of monro are described. Both the cases presented with clinical features of raised intracranial pressure and their cranial computerized scans (CT) revealed asymmetrical dilatation of lateral ventricles with displacement of septum pellucidum towards the side of smaller ventricle. Neuroendoscopic fenestration of septum pellucidum and foramen of monro was tried in both the cases, which remained successful in first, while the second case required unilateral ventriculoperitoneal shunt, due to failed endoscopic negotiation of narrowed foramen of monro and intraoperative bleeding during endoscopic intervention.
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The surgical outcome of 74 patients, who underwent transoral decompression (TOD) for ventral irreducible craniovertebral junction anomalies between January 1989 to September 1997, was studied to evaluate the perioperative complications and problems encountered. The indications for TOD included irreducible atlantoaxial dislocation (n=24), basilar invagination (n=16), and a combination of both (n=35). Following TOD, occipitocervical stabilization using Jain's technique was carried out in 50 (67.5%) and atlantoaxial fusion using Brooks' construct in 18 (24.3%) patients. ⋯ Of the 47 (63.5%) patients available at follow up ranging from 3 months to 2 years, 26 (55.3%) showed improvement from their preoperative status while 14 (29.8%) demonstrated stabilization of their neurological deficits. Seven (14.9%) of them deteriorated. Though TOD is logical and effective in relieving ventral compression due to craniovertebral junction anomalies, it carries the formidable risks of instability, incomplete decompression, neurological deterioration, CSF leak, infection and palatopharyngeal dysfunction.
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A seventy eight year old man sustained penetrating injury to right orbit about 15 years ago. Later he developed right orbital infection leading to phthisis bulbi. Two months before admission he developed CSF leak from the right orbit, tension pneumocephalous and meningitis. A rare case of CSF orbitorrhoea is reported here along with the discussion on mechanisms and management.