Nepal Journal of Neuroscience

Euthanasia: Are we ready for it, or is it too late?

Basant Pant — Sat, 31 Dec 2022 00:00:00 +0000

Euthanasia, also known as assisted suicide, is the act of intentionally ending the life of a person suffering from a terminal illness or incurable condition. The word "euthanasia" comes from the Greek words "eu," meaning "good," and "thanatos," meaning "death."¹ Passive euthanasia entails the withholding treatment necessary for the continuance of life. Active euthanasia entails the use of lethal substances or forces (such as administering a lethal injection), and is more controversial. Euthanasia is a highly sensitive issue under scrutiny from medical, ethical, religious, cultural and socio-economic viewpoints.

Persistent Primitive Trigeminal Artery – A Rare Vessel

Uddalok Das, Narayan Pandit — Sat, 31 Dec 2022 00:00:00 +0000

Primitive carotido vertebral anastomosis is a well-recognized entity. During intrauterine development, craniovertebral blood circulation is characterized by temporary connections between the primitive internal carotid and dorsal longitudinal neural arteries. With normal development, they regress in the prenatal period. The most common of these is a persistent primitive trigeminal artery (PPTA) We report the case of a young male patient with intracranial bleed in the left capsuloganglionic region who was subsequently found to have a persistent primitive trigeminal artery on Magnetic Resonance Imaging Angiography.

Neurological Deficits in Very Low Birth Weight Preterm Infants Among Covid- 19 Affected Mothers

Sat, 31 Dec 2022 00:00:00 +0000

Background: Premature infants undergo a lot of stressful procedures during care and treatment procedure, which may lead to physiological and neurological changes. This study is based on analyzing the neurological deficits in preterm infants with low birth weight born to covid-19 affected mothers. The main purpose of this study was to analyze whether the preterm infants with low birth weight are prone to develop neurological deficits. The aim of this study was to evaluate the neurological effects in preterm infants admitted to the NICU.

Method: Quasi experimental study design was used in this study; Total 10 Preterm infants admitted to the NICU who met the inclusion criteria were selected. All 10 preterm infants undergone screening for neurological deficits. All the data’s were tabulated and statistically analyzed.

Results: In very low birth weight infants and risk factors for development delay and neurosensory disability are high. Infants with very early Preterm and extreme low birth weight have a higher risk of attention problems, languages difficulties and intellectual disabilities.

Conclusions. It concludes that preterm infants are at risk of developing neurological deficits and also concludes that early the identification in new born helps in early the intervention to the new born

Outcomes of surgical excison of mass in the eloquent areas of brain : A prospective study at National Academy of Medical Sciences, Bir Hospital

Sat, 31 Dec 2022 00:00:00 +0000

Introduction: The treatment of choice for high and low-grade gliomas is primarily surgical resection, many gliomas of highly eloquent cortical regions still are not operated because of the impending risk of surgery-related deficits. Tumors of eloquent areas like sensorial, motor and language cortex need to be operated carefully so that the symptoms don’t worsen after surgery. However, Intra operative computerized tomography (IOCT), neuronavigation including optical as well as EM (electromagnetic), Neuromonitoring, stereotaxy and awake surgery increase safety, which allows resection of most of these tumors with a considerably low rate of new deficits postoperatively.

Materials and Methods: Between 2021 and 2022, a consecutive series of 30 patients who had undergone surgery for tumors on eloquent area of brain, at National Neurosurgical Referral Center (NNRC), National Academy of Medical Sciences (NAMS), Bir hospital were included in this study. Ethical approval was taken from Institutional review board (IRB) of NAMS for the study. Preoperative functional MRI, DTI scan that revealed mass in eloquent brain areas were evaluated. The preformed proforma was used to collect the data including preoperative karnofsky performance score, age, gender, clinical. Manifestations, size and location of tumor, degree of resection, pathological grade. Patient are followed postoperatively for 3 months and postoperative KPS, morbidity and mortality was recorded. SPSS version 22 was used for statistical analysis.

Results: Out of these 30 lesion were 13 (43.3%) were WHO grade IV, 5 (16.6% ) were WHO grade III astrocytoma, 3 (10% ) were WHO grade III oligodendroglioma , 2 (6.6% ) were WHO grade II astrocytoma, 4 ( 13.3%) were WHO grade I astrocytoma, 2 were tuberculoma and 1 was cavernoma. Majority of the patients (70%) (n=21 out of 30) presented with seizures. The mean age of the patient was 41.7 years (ranging from 21-71 years). Male predilection was observed accounting 60 % of the cases.

Conclusion: The surgery of eloquent areas of brain though carries the risk of increased post operative neurological deficit, with assistance of advanced technology and experienced surgeons it still feasible option especially for young patients with good karnosky score and low grade tumors which has improved overall survival.

Comparision between the Glasgow Coma Scale and Glasgow Coma Scale Pupil reactivity score in predicting mortality in traumatic brain injury patients

Puspa Koirala, Dipendra Shrestha, Suman Phuyal, Mohan Raj Sharma — Sat, 31 Dec 2022 00:00:00 +0000

Introduction: Glasgow Coma Scale (GCS) and the pupillary response are the key indicators of the severity of traumatic brain injury (TBI). Glasgow coma scale- Pupil reactivity (GCS-P) score is a tool to incorporate pupil reactivity and GCS into a simple single index. The main aim of this study was to compare GCS and GCS- P scores in predicting mortality in TBI patients in our institution.

Materials and Methods: All patients admitted to Tribhuvan University Teaching Hospital (TUTH) with moderate to severe head injury from May 2018 to April 2019 were included in the study. Both GCS and GCS- P scores were recorded separately at admission. Outcome was measured with Glasgow Outcome Scale (GOS) at the time of discharge and in three months. Diagnostic accuracy of both these scoring systems were calculated using receiver-operating characteristics (ROC) curve, and correlation between them was estimated by using Pearson correlation coefficient.

Results: Out of 136 patients enrolled, 98 patients had favorable outcome, 38 patients had unfavorable outcome at discharge. The Pearson correlation coefficient between GCS and GOS at discharge was 0.721 and GCS-P and GOS was 0.740 showing a good correlation between the GCS and GOS and GCS-P and GOS. The areas under ROC curve for GCS for prediction of mortality was 0.856 (95% CI; p<0.001) and for GCS-P is 0.871(95%CI;p<0.001) suggesting good discriminatory ability of both models. However, on statistical analysis, the discriminatory ability of GCS-P was not superior to GCS for mortality.

Conclusion: GCS-P is as good as but not superior to GCS in predicting mortality in traumatic brain injury patients.

Clinical and Radiological Profile and Early Outcome of Skull Base Surgeries in a Tertiary Care Center in Eastern Nepal

Sat, 31 Dec 2022 00:00:00 +0000

Background: Surgery of the skull base is challenging due to its complex anatomy and relative inaccessibility. Surgical anatomy and approaches to the cranial base have been well described in the neurosurgical literature.

Method: This is an analytical observational study consecutively treated from November 2019 to October 2021 at Nobel medical college teaching hospital, Biratnagar, Nepal. Clinical, radiological, intraoperative ad outcome data were retrieved through the chart review and prospectively collected computer database of the neurosurgery department. The outcome was accessed using mRS. Data was analyzed using Statistical Package for the Social Sciences (SPSS) 25^th version. Mean, median, percentage were analyzed. Chi-squared test was used to find out association between two populations for categorical variables. Logistic regression analysis was used to analyze preoperative selected variables and outcome. Outcome was assessed at discharge and in six months.

Results: A total of 61 cases were included in the study. There was a female preponderance in 73.8%. The mean age of the study population was 48.5 years. Headache was the most common presenting feature (45.9%) followed by loss of consciousness (21.3%). In the present study, 33(54%) had aneurysms, and 25(40.9%) had brain tumors. The most common approach was anterolateral 67.2% The most common complication observed was hydrocephalus (8.1%). The median duration of hospital stay was 12 days. The obese patients had significantly longer hospital stays (15 days). At discharge, a favorable outcome (mRS grade ≤ 2) was observed in 83.6%. The preoperative Glasgow coma scale (GCS) was significantly associated with the outcome.

Conclusion: Proper pre-operative evaluation and selection of appropriate approaches for the particular patients are key to achieving a good outcome in skull base surgery. The outcome is directly related to preoperative GCS and obese patients tend to have a longer hospital stay.

Age of readiness for epilepsy surgery

Galina Odinstova, Nina Dengina — Sat, 31 Dec 2022 00:00:00 +0000

Introduction The average time between epilepsy onset and epilepsy surgery is currently approximately 20 years. In epilepsy, research on the problem of late referral for neurosurgical treatment is crucial.

We aimed to investigate gender differences in the willingness of patients to undergo epilepsy surgery for focal drug-resistant epilepsy (DRE).

Methods. It was a single-centre retrospective, observational, longitudinal cohort study in the outpatient and functional neurosurgery departments. We developed a structured questionnaire to examine patients' demographic data, disease history, and perceptions of neurosurgical treatment (duration of epilepsy and optimal age for neurosurgery) in two gender groups. We examined data from 53 patients; eight people were dropped out from the research.

Results. Ninety-four point three per cent of outpatients and inpatients answered in the affirmative form the question about their willingness to undergo epilepsy surgery for focal DRE. There were 26 men in group one and 19 women in group two. The disease had been present for 19.26 ± 1.35 years before epilepsy surgery or the decision to undergo surgery. Patients with no significant gender differences between groups considered that the ideal age for neurosurgery was 18.66 ± 1.3 years and that the optimal duration of the disease was 6.94 ± 1.02 years, which was two point eight times shorter than the actual duration of epilepsy.

Conclusions. No gender differences in willingness to undergo surgical management of focal DRE were found. The subjective time in which a patient decides to undergo epilepsy surgery is much shorter than the objective time from epilepsy onset to neurosurgery. This could be one of the solutions to the problem of late referral for epilepsy surgery.

Neurosurgery as a Career Choice among Recent Medical Graduates from the Institute of Medicine, Nepal: A Cross-sectional Study

Sat, 31 Dec 2022 00:00:00 +0000

Introduction: The career choice of a medical graduate is often a complex process with multiple factors playing a part. Neurosurgery in Nepal is gradually growing and there is a huge interest in the academia to draw more graduates into neurosurgery. There is a paucity of data regarding the career choice of medical graduates from Nepal. The aim of this study was to determine the potential barriers and facilitators for choosing a future career as a neurosurgeon.

Methods: A descriptive cross-sectional study was carried out on all recent medical graduates in the last two weeks of their internship in 2021 from three medical colleges in Kathmandu. Variables included demographic characteristics, preferred specialty, willingness to choose neurosurgery and reasons for it, and the reasons for not choosing neurosurgery if done so. Frequency and percentages were used to describe the categorical variables. Mean and median were used to describe continuous variables. A comparison between two categorical variables (factors for choosing Neurosurgery as a career and factors that encouraged not to choose Neurosurgery) was made.

Results: Twenty-one out of 87 respondents preferred neurosurgery as their future career. The common motivating factors for choosing neurosurgery were innate interest in neurosurgery, motivation from seniors and mentors during clinical clerkship, and the glamour of the specialty. The main barriers were the perceived generally poor outcome of the neurosurgical patients, long hours of surgery, innate disinterestedness, long training and not having enough opportunities to get accredited training in the country.

Conclusion: Around Twenty-four percentage of graduates preferred neurosurgery as a future career. When the barriers are addressed there will probably be more medical graduates inclined to join Neurosurgery which will help in solving the shortage of neurosurgical manpower in Nepal.

A Cross-sectional Study on the Prevalence of Depression in Arunachal Pradesh

Tani Siram, Obang Perme, Ojing Komut — Sat, 31 Dec 2022 00:00:00 +0000

Introduction: Depression is a commonly occurring mental disorder. Depression affects patients across all age groups, socioeconomic statuses, and genders. To determine the prevalence of depression in patient attending OPD clinic in Pasighat, Arunachal Pradesh using the Patient Health Questionnaire (PHQ-9).

Methods: This is a cross-sectional study of fifty randomly selected patients in the OPD Clinic of Bakin Pertin General Hospital in Pasighat, Arunachal Pradesh, between the period 2017 and 2018. Eligible patients ranged in age from 13 to 70 years old and represented both rural and urban areas.

Results: The study found that twenty-one out of fifty patients, i.e., 42% of patients, suffered from minimal to mild depressive symptoms.

Conclusion: The study showed a high prevalence of depression in East Siang district (Pasighat), Arunachal Pradesh, and parts of adjoining districts of Pasighat. A combination of approaches could help in providing the best possible care for patients with mental disorders and assist them in living fulfilling lives.

Outcome of Depressed Cranial Fracture: A single centre Experience of 490 Cases with short literature Review

Mohan Karki, Yam Bahadur Roka — Sat, 31 Dec 2022 00:00:00 +0000

Introduction: Depressed cranial fractures (DCFs) are one of the serious head injuries where road traffic accident (RTA) is the most common cause. So, we have assessed the outcome in surgically managed cases of depressed cranial fracture following head injury and study the factors which may affect the surgical outcome of patients.

Materials and methods: A retrospective assessment of 490 consecutive cases was undertaken who went surgery for depressed cranial fracture (DCF) in Department of Neurosurgery, Neuro-Cardio and Multispecialty Hospital, Biratnagar, Nepal, from January 2011 to December 2021. All age groups (except< 1 year) were included in this study and diagnosis confirmed by CT scan of brain with bone window. Outcome was assessed by Glasgow outcome scale.

Results: The incidence of depressed cranial fracture was highest in road traffic accident (RTA) and in the age group of 20-40 years. There was predominance of male over female with ratio 5.53:1. There was a significant correlation between age, mode of injury, fracture site, GCS at admission and intracranial bleed with outcome. Similarly, the complications such as CSF leakage, seizure were significant association with outcome. Of all 490 cases, most of them were operated within 5 hour with overall mortality rate of 0.40%.

Conclusions: Our study concluded that patient who underwent surgery for DCFs, with GCS >13 at the time of admission, age <40 year and no hospital delay (<5hour) had better outcomes. Incidence of RTAs was noted comparatively higher rate in age 20-40 year, which can help us to find out best strategic management option.

Chronic Subdural Hematoma

Sajag Kumar Gupta — Sat, 31 Dec 2022 00:00:00 +0000

Chronic subdural haematoma (CSDH) is an encapsulated collection of old blood between the dura mater and arachnoid caused by tear of bridging veins. Chronic subdural haematoma is considered when the blood is more than three weeks old^. It is fairly common disease, especially in the elderly with incidence ranging 1.72 to 7. 35 per 100,000 population with male predominance. Elderly population is associated co- morbidities that can impact on immediate postoperative outcome and overall survival. Although history of trivial trauma is present in majority of cases but some cases may be secondary to coagulation defect, intracranial hypotension, and use of anticoagulant and antiplatelet agents. It commonly presents with headaches, confusion, drowsiness, vomiting, and seizures. On examination, patient have various neurological deficits including a low Glasgow coma scale, hemiparesis/hemiplegia, ocular palsy, and other deficits are seen .Diagnosis is usually confirmed by NCCT scan head however MRI are indicated for better visualisation of multiloculated intrahaematoma membranes.

Management of this condition is mostly surgery but some patients have also been managed conservatively with steroids. Steroids have been used in patient who have minor headache and also used in patients who are unfit for surgery.

Importance of Suspecting a Hemorrhagic Intracranial Lesion as Metastatic Choriocarcinoma

Sat, 31 Dec 2022 00:00:00 +0000

Though the brain metastasis from gestational trophoblastic neoplasia is rare, incidence is 3-21.4%. In this article, we report the rare case of a young female, presented with the features of raised Intracranial Pressure (ICP) with intracranial space occupying lesion, who was treated for tubercular abscess because she was clinically diagnosed as case of pulmonary TB from core biopsy of lung mass and was under Anti tubercular treatment at other center and the differential diagnosis of cavernoma bleed made from imaging modalities. However, to our surprise the histopathology came out as metastatic choriocarcinoma.

There was history of incomplete abortion 1 year back which could have developed from any gestational trophoblastic tissue resulting from a hydatidiform mole, miscarriage, or ectopic pregnancy. She gave this history after the histopathology came out as metastatic choriocarcinoma. The social tabu and going through traumatic experience, would be the region for her not to disclose the history before surgery. Although miscarriages are common and women continue to suffer in silence.

The rarity of brain metastasis from gestational trophoblastic neoplasia, there are still no guidelines on treatment strategies for these patients yet.

Malignant Epidermoid Cyst: MRI Evaluation and Review of Literature

Nivedita Jha, Amit Kumar — Sat, 31 Dec 2022 00:00:00 +0000

Epidermoid cysts are commonly encountered intracranial neoplastic masses in clinical radiology practice. They are purely benign but may undergo malignant transformation or may present as de novo malignant epidermoid tumor, a rare but ominous phenomenon associated with poor prognosis. Malignant epidermoids may masquerade as glial tumours, ependymal neoplasms, or choroid plexus masses, and are prone to be misdiagnosed. We describe a case of malignant epidermoid cyst or tumor (de novo) in a young adult who presented with the complaints of intermittent headaches which had increased in frequency and severity.

Challenges in Perioperative management of spontaneous acute subdural hematoma in haemophilia patients

Sachidanand Gautam, Manoj Singhal, Piyush Kumar Panchariya, Jigmisha Acharya — Sat, 31 Dec 2022 00:00:00 +0000

Intracranial hemorrhage in patients with hemophilia is associated with high mortality and morbidity. We report a case of 15 years old boy with haemophilia A, who presented with a spontaneous acute subdural hematoma and underwent craniotomy for clot evacuation. The patient also received Factor VIII infusions peri-operatively along with other measures, to decrease blood loss.

The patient presented with signs of raised intracranial pressure and received mannitol intra-operatively and postoperatively to prevent brain edema. Hypertonic saline (3 ml/kg of 3% solution) was also given over 30 minutes for brain relaxation. Recommendations for peri-operative preparation and management of haemophilia, especially in the setting of emergency major surgery were also reviewed.