Nepal Journal of Neuroscience <p>Official journal of the Nepalese Society of Neurosurgeons (NESON). Also available on its own site at <a title="NESON" href="" target="_blank" rel="noopener"></a></p> <p>The Nepal Journal of Neuroscience is now accepting online submissions. Please <a href="/index.php/NJN/user/register">register</a> with the journal and select the author role to be able to submit your manuscript using the 5 step submission process.</p> Nepalese Society of Neurosurgeons (NESON) en-US Nepal Journal of Neuroscience 1813-1948 Calendar of events (from Jan 2022 till March 2022) <p>Calender of events</p> Amit Thapa Copyright (c) 2021 Nepalese Society of Neurosurgeons (NESON) 2021-11-30 2021-11-30 18 4 76 76 Concept of 'Central' or 'Axial' Atlantoaxial Instability <p>The atlantoaxial joint is the most mobile joint of the spine and is most liable to develop instability. Atlantoaxial instability can be identified on observation of facetal alignment on lateral profile imaging, telltale clinical and radiological evidence and by direct observation of instability by manual manipulation of bones during surgery. Central or axial atlantoaxial instability is when there is no abnormal increase in atlantodental interval on dynamic imaging and there is no dural or neural compression by the odontoid process. Understanding and appropriately treating central or axial atlantoaxial instability can have clinical implications.</p> Atul Goel Copyright (c) 2021 Nepalese Society of Neurosurgeons (NESON) 2021-11-30 2021-11-30 18 4 4 11 10.3126/njn.v18i4.40826 MR Imaging Spectrum of Neuro Rhino Sino Orbital Fungal Infections in patients treated for COVID <p><strong>Objectives: </strong>To analyse the spectrum of imaging findings of fungal infection as seen in MRI images of priorly treated for COVID.</p> <p><strong>Materials and methods: </strong>The different patterns of findings of Neuro Rhino Sino Orbital Fungal Infections as seen in MRI images in 100 patients who received standard treatment for COVID in recent past and presented with suggestive signs and symptoms. </p> <p><strong>Results: </strong>No positive MRI findings to suggest any neural tissue, orbital or Sino nasal involvement was seen in 35 % of cases. Only sino nasal involvement noted in 23 % cases. Sino-nasal as well as orbital involvement seen in 21 % cases. Neuro Sino Naso Orbital lesions were seen in 11% cases. Non fungal orbito-facial soft tissue inflammation was seen in 10 % cases.</p> <p><strong>Conclusion: </strong>In patients who have received standard treatment for Covid and who later developed signs and symptoms of neural, orbital or Sino nasal involvement; positive imaging findings were noted in 65% cases. Fungal infections were seen more in middle aged population [40-60 years of age]. About 75 % of affected patients were known diabetics. Neural involvement was least common. This study proposes a new staging system [Stage 0, X, I, II, III, IV] for describing the affected region by fungal infection.</p> Sushil Ghanshyam Kachewar Smita Kachewar Copyright (c) 2021 Nepalese Society of Neurosurgeons (NESON) 2021-11-30 2021-11-30 18 4 19 25 10.3126/njn.v18i4.37486 Prognostication of Traumatic Brain Injury using International Mission for Prognosis and Analysis of Clinical Trials in Traumatic Brain Injury score in Nepalese Cohort <p><strong>Introduction: </strong>Traumatic brain injury disease of major importance globally. Prognostic models are useful for making decisions in the clinical practice. The aim of this study was to assess the accuracy of International Mission for Prognosis and Analysis of Clinical Trials in TBI (IMPACT) score in predicting outcome in moderate to severe TBI at 3 months. </p> <p><strong>Materials and Methods: </strong>All patients admitted to National Trauma Center, National Academy of Medical Sciences with moderate to severe traumatic brain injury from February 2020 to February 2021 were included in the study. IMPACT scores (core/extended core/ lab) were recorded separately at admission. Outcome was measured with Glasgow Outcome Scale (GOS) at the time of discharge and at six months<strong>. </strong>Correlation between observed and predicted outcomes was evaluated by Pearson’s correlation coefficient (r). Sensitivity and specificity were plotted in the receiver-operating characteristic (ROC) curve, and the area under the curve (AUC) was calculated to determine the discrimination ability of this prognostic model.</p> <p><strong>Results: </strong>A total of 112 patients were enrolled in the study. Eighty (71.4 %) patients had moderate and 32 (28.57 %) had severe TBI. The median age was 33 years with male preponderance (M: F=4:1). Thirty three (29.5 %) patients died within 6 months of TBI, and 38 (33.9 %) patients had an unfavorable outcome. Pearson correlation coefficient showed good correlation between observed and predicted outcomes. Hosmer-Lemeshow test showed good model fit for IMPACT core, IMPACT extended and IMPACT lab in diagnosing mortality and unfavorable outcome in six months (p&gt;0.05). The ROC curve indicated that all 3 models could accurately discriminate between favorable and unfavorable outcomes, as well as between survival and mortality (unfavorable outcome AUC= 0.905, 0.940, 0.955; mortality AUC= 0.875, 0.914, 0.917 respectively) in our patient population.</p> <p><strong>Conclusion: </strong>The IMPACT score is a good prognostic model to predict 6-month outcomes in moderate to severe TBI at admission in Nepalese patient population. Among the three IMPACT models, IMPACT lab has the greatest discriminating ability. </p> Binit Kumar Jha Prabhat Jha Bikesh Khambu Rajendra Shrestha Rajiv Jha Prakash Bista Copyright (c) 2021 Nepalese Society of Neurosurgeons (NESON) 2021-11-30 2021-11-30 18 4 26 32 10.3126/njn.v18i4.38739 Prognostic Indicators in Patients with Intracerebral Hematoma in an urban clinical setting of a resource limited Country <p><strong>Context and Objective: </strong>Hemorrhagic Cerebrovascular Accidents represent 10 to 15% of all strokes and are often related to the spontaneous rupture of small vessels weakened by chronic arterial hypertension or amyloid angiopathy. The aim of this work was to study the prognostic determinants of intracerebral haematomas at the neurology department of Conakry University Hospital.</p> <p><strong>Patients and Method:</strong> This was a retrospective analytical study conducted on all patients who were hospitalized with intracerebral hematoma over the 24-month period. Only the records of patients in whom intracerebral hematoma was confirmed by brain imaging were included in this study. Logistic regression (uni-variate and multi-variate) identified prognostic determinants of intracerebral hematoma at p &lt; 0.05. The data were entered using Epi Info software version then analysed using STATA / SE software version 11.2.</p> <p><strong>Results: </strong>This study found 21% of cases of intracerebral hematomas during the study period, with a male predominance of 60% and a sex ratio of 1.50. The study was conducted in the presence of a male patient. Hypertension was the cause found in 89.52% of patients; followed by arteriovenous malformations in 6.67% of patients, 2.86% of cases of amyloid angiopathy and 0.95% of unknown cause. Nevertheless, we still recorded 20% of deaths during hospitalization.</p> <p><strong>Conclusion: </strong>Previous quality of life and co-morbidities also modify the prognosis and should be taken into account in the prediction of disability and future quality of life of patients with intracerebral haematoma.</p> Hugues Ghislain Atakla Fatoumata Lounceny Barry Mahugnon Maurel Ulrich Dénis Noudohounsi Benjamin Bekoe Ofosu Ummi Sulaimi Sulemana Dismand Stephan Houinato Copyright (c) 2021 Nepalese Society of Neurosurgeons (NESON) 2021-11-30 2021-11-30 18 4 33 38 10.3126/njn.v18i4.36701 Reviewers of 2021 <p>Reviewers of 2021</p> Amit Thapa Copyright (c) 2021 Nepalese Society of Neurosurgeons (NESON) 2021-11-30 2021-11-30 18 4 75 75 Intrathecal Colistin and Intravenous Fosfomycin as a combination therapy for the treatment of Acinetobacter baumannii Ventriculitis and meningitis: a case report from Nepal <p>Treatment of central nervous system infection may be troublesome due to multi-drug resistance. Colistin is less successful as a treatment option due to poor CNS penetration when used intravenously. We present the successful management of a case with ventriculitis and meningitis due to MDR Acinetobacter baumannii species with the combined intraventricular administration of colistin and IV fosfomycin after the initial regimen of colistin given alone through both IVT and IV routes had failed.</p> Bikash Khadka Saroj Poudel Copyright (c) 2021 Nepalese Society of Neurosurgeons (NESON) 2021-11-30 2021-11-30 18 4 39 43 10.3126/njn.v18i4.37518 Dramatic improvement of segmental Zoster Paresis by late-onset antiviral therapy <p>Focal paresis secondary to Herpes zoster (HZ) is a rare neurological complication and should be kept in mind in the differential diagnosis of acute weakness with corresponding dermatomal rashes. In this case report, we illustrate an 84-year-old male patient, who presented with focal upper extremity weakness following HZ on right C4-8 dermatome. After clinical and electrophysiological evaluations, segmental zoster paresis was diagnosed. Although antiviral medication(oral <em>brivudine)</em> had been administered previously, oral valacyclovir and low dosage methylprednisolone were initiated. In the following 2 months interval, a progressive and dramatic recovery in extremity weakness and neuropathic pain were achieved. The clinical course of this patient may give substantial perspectives regarding the clinical evaluation of similar cases.</p> Halil Onder Gokcen Celik Copyright (c) 2021 Nepalese Society of Neurosurgeons (NESON) 2021-11-30 2021-11-30 18 4 44 48 10.3126/njn.v18i4.36631 Non-functional pituitary carcinoma <p>We present as case to review and present the clinical features, diagnosis and treatment of non-functional pituitary carcinoma (NFPC).</p> <p>We operated on a case of NFPC. After surgery, gamma knife therapy, temozolomide chemotherapy and whole craniospinal irradiation, the patient still had poor tumor control and died 7 months after operation.</p> <p>FPC is very rare. It needs to be diagnosed with a combination of clinical suspicion, imaging and dynamic monitoring. It is necessary to find more effective methods to control the progress of tumor while routine treatment fails.</p> Haiyong He Ying Guo Manting Li Lun Luo Robin Bhattarai Wensheng Li Copyright (c) 2021 Nepalese Society of Neurosurgeons (NESON) 2021-11-30 2021-11-30 18 4 49 53 10.3126/njn.v18i4.39301 Pseudotumor Cerebri in the Setting of Differentiation Syndrome in a Patient with Acute Promyelocytic Leukemia Treated with All-trans Retinoic Acid During Induction Therapy <p><strong>Introduction: </strong>Differentiation syndrome, a well-known complication of all-<em>trans</em> retinoic acid (ATRA) in patients with acute promyelocytic leukemia (APML), can very rarely have ophthalmic manifestations. Pseudotumor cerebri (PC) in the setting of differentiation syndrome (DS) in patients undergoing induction with all-<em>trans</em> retinoic acid has rarely been reported elsewhere. We herein report one such case.</p> <p><strong>Case Presentation: </strong>A 28-year-old, non-obese female diagnosed as acute promyelocytic leukemia underwent induction with all- <em>trans </em>retinoic acid and Idarubicin. On day 4 of the treatment, she developed high grade fever (104 – 105 F), dry cough, hypotension, tachycardia, and tinnitus. Chest X ray showed floppy shadows in bilateral lungs. On physical examination, bilateral lower limb edema was noted. She also experienced sudden weight gain of 5 kilogram in 48 hours. After careful exclusion of systemic infection, she was suspected as having DS. She also noticed a reduction in vision in right eye. On eye examination, her best-corrected visual acuity (VA) was 6/60 in the right eye (RE) and 6/6 in the left eye (LE). Fundus evaluation revealed bilateral disc edema with peripapillary hemorrhages along with slight tortuosity of vessels and a yellowish lesion over the fovea in RE. Suspecting DS, she was treated with injection dexamethasone 10 mg twice daily and all- <em>trans </em>retinoic acid was temporarily discontinued. Immediately after its discontinuation, her headache lessened and vision improved gradually. After 2 weeks, her VA was 6/12 in RE and 6/6 in LE which improved to 6/6 in both eyes at 3 months. The patient was also receiving oral voriconazole for fungal prophylaxis and the potentiation effect of all- <em>trans </em>retinoic acid could thus be explained.</p> <p><strong>Conclusion: </strong>Pseudotumor cerebri associated with all-<em>trans</em> retinoic acid treatment in acute promyelocytic leukemia, even though frequently reported in pediatric patients, is rare in adults. Ophthalmological evaluation is mandatory in all these patients under all-<em>trans</em> retinoic acid therapy.</p> Barsha Suwal Bishesh Sharma Poudyal Rabindra Adhikary Copyright (c) 2021 Nepalese Society of Neurosurgeons (NESON) 2021-11-30 2021-11-30 18 4 54 58 10.3126/njn.v18i4.39199 Intracranial Infection Caused by Multidrug-resistant Acinetobacter Baumannii <p><strong>Objective:</strong> To report the successful treatment of a patient who underwent vestibular schwannoma resection and developed intracranial infection caused by multidrug-resistant Acinetobacter baumannii (MRAB), and to review the recent relevant literature.</p> <p><strong>Methods:</strong> The patient was diagnosed with MRAB infection based on clinical manifestations and cerebrospinal fluid (CSF) culture. The treatment included external ventricular drainage, posterior fossa decompressive craniectomy, and endoscopic lavage for fourth ventricle, subdural drainage, and intravenous injection /ventricular irrigation of sulperazone.</p> <p><strong>Results:</strong> The MRAB-induced intracranial infection was successfully cured. The follow-up lasted for 84 months, and the patient has resumed normal life and work.</p> <p><strong>Conclusion:</strong> Active individualized treatment should be administered at the earliest. The drainage of CSF, ventricular lavage, and proper choice of antibiotics are key to treat intracranial infections caused by MRAB.</p> Haiyong He Manting Li Ying Guo Lun Luo Robin Bhattarai Wensheng Li Copyright (c) 2021 Nepalese Society of Neurosurgeons (NESON) 2021-11-30 2021-11-30 18 4 59 63 10.3126/njn.v18i4.39401 Dealing with COVID-19 in Medical Practice: Yet an Uncertain Situation <p>COVID-19 pandemic is still uncertain and is going to last longer. The world has learnt a lot to fight against it. However, the world has to learn to live and deal with it in the days ahead. Medical practice has to be innovated and modified to protect medical professionals as well as patients.</p> Prabin Shrestha Copyright (c) 2021 Nepalese Society of Neurosurgeons (NESON) 2021-11-30 2021-11-30 18 4 1 3 10.3126/njn.v18i4.40757 Predictive Value of Cerebrospinal Fluid Lactate Level for the Diagnosis of Bacterial Meningitis following Cranial Surgery <p><strong>Background:</strong>To distinguish post-neurosurgical bacterial meningitis (PNBM) from aseptic meningitis is difficult. Inflammatory and biochemical cerebrospinal fluid (CSF) changes mimic those classically observed after CNS surgery. CSF lactate assay has therefore been proposed as a useful PNBM marker.</p> <p><strong>Objective:</strong>To determine the value of cerebrospinal fluid (CSF) lactate level for the identification of bacterial meningitis following cranial surgery.</p> <p><strong>Methods:</strong>Between January 2016 and December 2016, a prospective clinical study was done in Department of Neurosurgery, in which all patients with clinical suspicion of PNBM were enrolled. Patients with clinical suspicion of bacterial meningitis BM were categorized, according to preset criteria, into 3 groups: (1) proven BM; (2) presumed BM, and (3) nonbacterial meningeal syndrome. CSF markers were plotted in a receiver operating curve (ROC) to evaluate their diagnostic accuracy.</p> <p><strong>Results:</strong>The study included 70 patients. We obtained 65 CSF samples from patients with clinical suspicion of BM by CSF analysis. 20 corresponded to proven BM, 7 to probable BM and 38 to excluded BM. Mean lactate in CSF was: 8.4 ±3.0 mmol /l for proven BM, 4.8 ± 0.99 mmol /l for probable BM and 2.08 ± 0.822 mmol/l for excluded BM (<em>P </em>&lt; .001).</p> <p><strong>Conclusion</strong>: CSF lactate level has good predictive value to distinguish BM from aseptic meningitis with sensitivity of 90% and specificity: 87% at cut-off value: 4.0 mmol/l.</p> Ashok Kharel Gopal Sedain Sushil krishna Shilpakar Mohan Raj Sharma Copyright (c) 2021 Nepalese Society of Neurosurgeons (NESON) 2021-11-30 2021-11-30 18 4 12 18 10.3126/njn.v18i4.31171 Retinoblastoma Extending up to the Optic Chiasma and Presenting as a Suprasellar Mass <p>Retinoblastoma is the most common ocular malignancy of childhood. It is present in childhood with leukocoria and strabismus. Most patients are diagnosed under 3 years of age.</p> <p>Funduscopic examination can reveal an intraocular mass, but imaging is essential for complete evaluation of the lesion. Although ultrasound is a non-invasive and relatively inexpensive screening tool, cross-sectional imaging is required to assess the involvement of optic nerve and intracranial spread.</p> <p>We report a case of retinoblastoma in a 5 year old male child who presented with headache diminution of vision in both eyes. Contrast enhanced magnetic resonance imaging (MRI) revealed an enhancing soft tissue mass in the right eye with involvement of optic nerve and optic chiasma and contiguous with a large suprasellar mass causing hydrocephalus. Non-contrast computed tomography (CT) showed extensive calcifications in the mass lesion.</p> Himanshu Mishra Amit Kumar Copyright (c) 2021 Nepalese Society of Neurosurgeons (NESON) 2021-11-30 2021-11-30 18 4 64 67 10.3126/njn.v18i4.37248 Non-dysraphic Subpial Intramedullary Lipoma of Cervicothoracic Spine <p>Intramedullary spinal cord tumors are rare and comprise less than one percentage of all<a href=""> central nervous system (CNS) neoplasms</a>. When encountered, most are found in the lumbosacral region with coinciding spinal dysraphism. Here, we discuss a case of isolated non-dysraphic intramedullary lipoma of cervicothoracic spine in an adolescent who was surgically managed with posterior decompression and subtotal resection via laminoplasty.</p> <p>A 21-year-old male adolescent, without a history of spinal dysraphism, presented with a progressive sensory ataxia. This manifestation was attributed to magnetic resonance documented intramedullary lipoma, extending from C7 to T2 spinal level. Patient underwent subtotal surgical resection of the lesion; and histopathology report was confirmed as spinal lipoma.</p> <p>Surgical management of this rare pathology has a wide variety of options depending on clinical presentation. In our case, a subtotal resection and laminoplasty was achieved with no further worsening of neurologic symptoms.</p> Aliza Hamal Anjan Singh Karki Ashim Gurung Dipendra Kumar Shrestha Sushil Krishna Shilpakar Copyright (c) 2021 Nepalese Society of Neurosurgeons (NESON) 2021-11-30 2021-11-30 18 4 68 71 10.3126/njn.v18i4.35418 Rare Case of Wernicke Encephalopathy with Initial Negative Diffusion-Weighted Imaging <p>In this report, we present a rare patient with Wernicke encephalopathy (WE) in whom the initial magnetic resonance imaging (MRI) was normal. However, cranial MRI, performed two weeks later, showed lesions compatible with WE. Via the presentation of this patient, we discuss the need for future studies of larger cases including the temporal evaluation of the MRI characteristics of Wernicke encephalopathy.</p> Halil Onder Serdar Kirmizi Copyright (c) 2021 Nepalese Society of Neurosurgeons (NESON) 2021-11-30 2021-11-30 18 4 72 74 10.3126/njn.v18i4.36629