Neurology Commons^™

Secretory Paraspinal Paraganglioma Of Thoracolumar Spine: Case Report And Review Of Literature, Saad Akhtar, Sidra Sattar, Muhammad Ehsan Bari, Naila Kayani, Sarosh Moeen

Section of Neurosurgery

Background: Pheochromocytomas are catecholamine secreting tumors of the adrenal medulla chromaffin cells, however, when present extra-adrenally they are called paragangliomas. Paragangliomas rarely produce catecholamine in excess, which is evident by clinical symptoms, urine, and blood biochemistry. Total resection of these tumors can lead to complete clinical and biochemical resolution. This case report presents the clinical features, radiological findings, and neurological outcome in a middle-aged female with a secretory paraganglioma.
Case description: We present the case of a 34-year-old female who presented with a 2-year history of dizziness, flushing, headache, palpitations, and hypertension. Her blood workup showed raised urinary catecholamine levels. …

Raman Spectroscopy Detects Distant Invasive Brain Cancer Cells Centimeters Beyond Mri Capability In Humans, Michael Jermyn, Joannie Desroches, Jeanne Mercier, Karl St-Arnaud

Dartmouth Scholarship

Surgical treatment of brain cancer is limited by the inability of current imaging capabilities such as magnetic resonance imaging (MRI) to detect the entirety of this locally invasive cancer. This results in residual cancer cells remaining following surgery, leading to recurrence and death. We demonstrate that intraoperative Raman spectroscopy can detect invasive cancer cells centimeters beyond pathological T1-contrast-enhanced and T2-weighted MRI signals. This intraoperative optical guide can be used to detect invasive cancer cells and minimize post-surgical cancer burden. The detection of distant invasive cancer cells beyond MRI signal has the potential to increase the effectiveness of surgery and directly …

Duration Of Posttraumatic Amnesia Predicts Neuropsychological And Global Outcome In Complicated Mild Traumatic Brain Injury., Tessa Hart, Thomas A. Novack, Nancy Temkin, Jason Barber, Sureyya S. Dikmen, Ramon Diaz-Arrastia, Joseph Ricker, Dale C. Hesdorffer, Jack Jallo, Nancy H. Hsu, Ross Zafonte

Department of Neurosurgery Faculty Papers

OBJECTIVES: Examine the effects of posttraumatic amnesia (PTA) duration on neuropsychological and global recovery from 1 to 6 months after complicated mild traumatic brain injury (cmTBI).

PARTICIPANTS: A total of 330 persons with cmTBI defined as Glasgow Coma Scale score of 13 to 15 in emergency department, with well-defined abnormalities on neuroimaging.

METHODS: Enrollment within 24 hours of injury with follow-up at 1, 3, and 6 months.

MEASURES: Glasgow Outcome Scale-Extended, California Verbal Learning Test II, and Controlled Oral Word Association Test. Duration of PTA was retrospectively measured with structured interview at 30 days postinjury.

RESULTS: Despite all having a …

Awake Craniotomy For Brain Tumours In Pakistan: An Initial Case Series From A Developing Country, Saad Akhtar Khan, Karim Rizwan Nathani, Badar Uddin Ujjan, Muhammad Danish Barakzai, Ather Enam, Faraz Shafiq

Section of Neurosurgery

Awake craniotomy offers safe resection of brain tumours in eloquent area. Aga Khan University Hospital, Karachi, recently started the programme in Pakistan, and the current study was planned to assess our experience of the first 16 procedures. The retrospective study comprised all such procedures done from November 2015 to May 2016. Pre-operative and post-operative variables were analysed. Of the 16 patients, 11(68.75%) were males and 5(31.25%) were females. The overall median age was 37 years (interquartile range[IQR]: 23-62 years). The most common presenting complaint was seizures 8(50%), followed by headache6(38%). The common pathologies operated include oligodendroglioma and glioblastoma. Pre-operative mean …

Paediatric Traumatic Brain Injury: Presentation, Prognostic Indicators And Outcome Analysis From A Tertiary Care Center In A Developing Country, Badar Uddin Ujjan, Muhammad Waqas, Muhammad Babar Khan, Dr Saqib Kamran Bakhshi, Muhammad Ehsan Bari

Section of Neurosurgery

Traumatic brain injury (TBI) is the leading cause of morbidity and mortality in children worldwide. This study was conducted to report the presentation, management, outcomes and prognostic indicators in a large series of patients from a tertiary care centre in a developing country. It is a review of prospectively collected data of paediatric patients with TBI admitted at our centre between July 2010 and December 2013. A total of 291 patients with a mean age of 7.2±5.0 years were dichotomised into survivors and non-survivors, and variables were compared between the two groups. The mean post-resuscitation Glasgow coma scale (GCS) score …

Exploring Patient And Family Satisfaction In Pediatric Neurological Surgery, Randa R. Barsoom, Todd A. Maugans, James F. Burrows, Paul Rosen

Student Papers, Posters & Projects

Introduction Patient and family satisfaction during outpatient visits is correlated with a continuance of care and likelihood to recommend the practice to others. Additionally, patient-family satisfaction can determine the success of the practice and influence medical outcomes. Utilizing a well-validated surveys instrument, patient and family satisfaction can be explored in the office setting. Methods During a consecutive 36 month period, a standardized and validated patient satisfaction survey instrument was provided to the family members of patients who presented to two pediatric neurosurgery clinics associated with Nemours Children's Health System. The completed surveys were analyzed statistically to identify correlations between overall …

Co-Existing Spinal Intradural Ependymal Cyst And Sacral Tarlov Cyst In Adult-Onset Tethered Cord Syndrome With Syringomyelia: Case Report And Literature Review, Hamid H. Rai, Muhammad F. Khan, Ather Enam, Imtiaz Hashmi

Section of Neurosurgery

Background: Synchronous spinal intradural ependymal cysts and sacral Tarlov cysts in adult onset tethered cord syndrome are extremely rare.
Case description: A 23-year-old male presented with back pain radiating into both lower extremities, accompanied by acute onset of gait difficulty and sphincter dysfunction. Magnetic resonance imaging identified a low lying conus medullaris, syringomyelia with septations extending from T12 to S1, a tethered cord, and a thickened filum terminale with a sacral Tarlov cyst. The patient underwent a L3-4 laminectomy for decompression of syringomyelia and excision/biopsy of a space occupying lesion along with S1-2 laminectomy for cord untethering and Tarlov cyst …

Management And Outcomes Of Intramedullary Spinal Cord Tumors: A Single Center Experience From A Developing Country, Dr Saqib Kamran Bakhshi, Muhammad Waqas, Baila Shakaib, Ather Enam

Section of Neurosurgery

Background: Intraoperative neurophysiology, high magnification microscopes, and ultrasonic aspirators are considered essential aid for the safe resection of intramedullary spinal cord tumors (IMSCTs). Most centers in developing countries such as Pakistan still lack these facilities. The purpose of this study was to review the management of IMSCTs at our hospital and to determine factors associated with the outcomes of surgery.
Methods: This was a retrospective review of medical records of adult patients undergoing surgery for IMSCT over 12 years. The institutional ethical review committee approved this study. Data were collected regarding demographics, clinical and radiological features, and surgical details. Modified …

Non-Psychotropic Cannabinoid Based Therapy Modulates Nociceptive Signaling Molecules, Microglia, And Pain Behavior In A Model Of Post-Concussion Headache, Jarred M. Stratton, Lan Cheng, Ashley L. Tyburski, Jessica Perino, Melanie B. Elliott

Department of Neurosurgery Posters

Background & Objectives

Headache is a common symptom of post-concussion syndrome which may persist in a substantial portion of patients contributing to a poor quality of life and disability. There is a pressing need to develop novel treatments for post-traumatic headache as current treatments have a number of side effects, are contraindicated or lack efficacy. The Elliott laboratory first established models of post-traumatic headache demonstrating sensitization of trigeminal neurons in rodent models of post-traumatic headache using well-known nociceptive and behavioral markers in the pain and migraine fields^1-3. Traumatic brain injury in mice increases expression of calcitonin gene related …

The (R)- Isomer Of Isometheptene Decreases Trigeminal Sensitivity In A Rat Model Of Primary Headache, Jessica Perino, Ms, Nathan T. Fried, Phd, Michael L. Oshinsky, Phd, Bruce Daugherty, Phd, Mba, Seth Lederman, Md, Melanie B Elliott, Phd

Department of Neurosurgery Posters

Introduction

Isometheptene is thought to be the active ingredient of the commonly known headache medication, Midrin. Previously, we found only the (R) enantiomer to be effective in alleviating headache behavior in two models of headache compared to the (S) enantiomer.

Experiments using electrical and mechanical stimulation of the dura in animals with no history of head pain have been used to elucidate the mechanisms of the trigeminovascular system at the level of the trigeminal ganglion, trigeminal nucleus caudalis, periaqueductal gray, and the thalamus. The limitation of these acute models is that electrical and mechanical stimulation of the dural blood vessels …

Cerebral Aspergillosis And Pulmonary Tuberculosis In A Child With Chronic Granulomatous Disease, Muhammad Waqas, Sidra Zafar, Tooba Rehman, Muhammed Riyaz, Muhammad Ehsan Bari, Romana Idress

Section of Neurosurgery

Background: Chronic granulomatous disease (CGD) is an immune disorder that affects phagocytes. It is characterized by recurrent or persistent bacterial and fungal infections. Reports of tuberculosis (TB) in patients with CGD are rare. In developing countries, where TB is endemic, possibility of other chronic infections is often overlooked by physicians.
Case description: We report the case of a 4-year-old boy who had recurrent respiratory infections and episodes of headache. He was put on antituberculosis (ATT) drugs without microbiological or pathological evidence 2 months prior to presentation. The child did not improve and was brought to our hospital where a computed …

Intraoperative Neurophysiological Monitoring For Endoscopic Endonasal Approaches To The Skull Base: A Technical Guide., Harminder Singh, Richard W. Vogel, Robert M. Lober, Adam T. Doan, Craig I. Matsumoto, Tyler J. Kenning, James J. Evans

Department of Neurosurgery Faculty Papers

Intraoperative neurophysiological monitoring during endoscopic, endonasal approaches to the skull base is both feasible and safe. Numerous reports have recently emerged from the literature evaluating the efficacy of different neuromonitoring tests during endonasal procedures, making them relatively well-studied. The authors report on a comprehensive, multimodality approach to monitoring the functional integrity of at risk nervous system structures, including the cerebral cortex, brainstem, cranial nerves, corticospinal tract, corticobulbar tract, and the thalamocortical somatosensory system during endonasal surgery of the skull base. The modalities employed include electroencephalography, somatosensory evoked potentials, free-running and electrically triggered electromyography, transcranial electric motor evoked potentials, and auditory …

Acute Cerebellitis Successfully Managed With Temporary Cerebrospinal Fluid Diversion Using A Long Tunnel External Ventricular Drain: A Long-Term Radiological Follow-Up Of Two Cases, Muhammad Waqas, Yousaf Bashir Hadi, Sadaf Sheikh, Muhammad Shahzad Shamim

Section of Neurosurgery

Acute cerebellitis (AC) is a rare inflammatory childhood disorder. Although there is no consensus on standard treatment for cerebellitis, its outcome is usually favourable. We report two cases of AC in the paediatric age group, successfully managed with long tunnel external ventricular drain (EVD). The first patient was an 8-year-old boy with a history of fever and headache. Sequential MRI showed diffuse cerebellar swelling with tonsillar herniation and resulting hydrocephalus. The second patient was a 6-month-old boy who presented with high-grade fever associated with chills. CT scan of the head showed triventricular hydrocephalus with obliteration of cerebrospinal fluid spaces and …

Composite Split Cord Malformation Associated With A Dermal Sinus Tract, Dermoid Cyst, And Epidural Abscess: A Case Report And Review Of Literature, Saad Akhtar, Abdul Azeem, Muhammad Shahzad Shamim, Muhammad Zubair Tahir

Section of Neurosurgery

Background: Split cord malformation (SCM) is typically present at a single level but rarely, may be present at multiple levels in the spinal cord and can be associated with a wide array of lesions such as myelomeningoceles, lipomas, teratomas, and dermal sinus tracts (DSTs).
Case description: We describe a case of a 15-month-old female child who presented with high-grade fever and progressive motor weakness in the lower limbs. Magnetic resonance imaging revealed the presence of SCM along with an epidural abscess, DST, and dermoid cyst. The child underwent surgery for excision of DST along with removal of the dermoid cyst …

Providing Care Beyond The Hospital: Perspective Of A Tertiary Care Hospital From A Developing Country, Saad Akhtar, Muhammad Waqas, Badar Uddin Ujjan, Adnan Salim, Gohar Javed, Syed Ijlal Ahmed, Malikah Surani, Marium Khan

Section of Neurosurgery

Background: Neurorehabilitation is an important aspect of continuing care for neurosurgical patients with functional disability. In developing countries, where formal home nursing frequently is unavailable, ensuring care after discharge is a difficult task. Training attendants to provide nursing care is an alternate option. In this study, we compared the outcomes of patients nursed by family members versus those looked after by a professional nurse.
Methods: This was a retrospective observational study conducted at the Aga Khan University Hospital Karachi. The study consisted of 2 groups. Group 1 (consisting of patients cared for by a professional nurse) included 94 patients and …

Long-Tunneled Versus Short-Tunneled External Ventricular Drainage: Prospective Experience From A Developing Country, Muhammad Zubair Tahir, Zain A. Sobani, Muhammed Murtaza, Ather Enam

Section of Neurosurgery

Background: External ventricular drains (EVD) are commonly utilized for temporary diversion of cerebrospinal fluid (CSF). Many neurosurgeons prefer long-tunneled EVDs in their routine practice. However, it is still unclear whether this extended tunneling helps in reducing CSF infection. Keeping this in mind, we decided to compare infection rates in long-tunneled versus short-tunneled EVDs in the setting of a developing country.
Materials and methods: A prospective study of 60 patients was conducted. Consenting patients who underwent short-tunneled (Group A) or long-tunneled (Group B) EVDs between January 2008 and June 2009 were followed during the course of their inpatient care. All operational …

Response To: Computed Tomography-Guided Biopsy For Potts Disease: An Institutional Experience From An Endemic Developing Country, Muhammad Waqas, Faizuddin Najmuddin, Mohammad Ali Alvi, Muhammad Ehsan Bari

Section of Neurosurgery

No abstract provided.

Cerebellopontine Angle Primitive Neuroectodermal Tumor Mimicking Trigeminal Schwannoma, Saad Akhtar Khan, Badar Uddin Ujjan, Adnan Salim, Muhammad Shahzad Shamim

Section of Neurosurgery

Background: Primitive neuroectodermal tumors (PNETs) comprise a group of aggressive, poorly differentiated embryonal tumors occurring in central nervous system as well as in peripheral locations. Primary cerebellopontine angle (CPA) PNET is an extremely rare entity. It is important to have knowledge of this pathology and to be able to differentiate it from other commonly occurring CPA tumors, such as vestibular and trigeminal schwannomas. This distinction is essential because of the difference in the overall treatment plan and prognosis.
Case description: This report describes a case of a young male presenting with diplopia and numbness of face; magnetic resonance imaging showed …

Radioresistance Of Brain Tumors, K. Kelley, J. Knisely, M. Symons, R. Ruggieri

Journal Articles

Radiation therapy (RT) is frequently used as part of the standard of care treatment of the majority of brain tumors. The efficacy of RT is limited by radioresistance and by normal tissue radiation tolerance. This is highlighted in pediatric brain tumors where the use of radiation is limited by the excessive toxicity to the developing brain. For these reasons, radiosensitization of tumor cells would be beneficial. In this review, we focus on radioresistance mechanisms intrinsic to tumor cells. We also evaluate existing approaches to induce radiosensitization and explore future avenues of investigation.

Outcomes In Patients With Vestibular Schwannoma After Subtotal Resection And Adjuvant Radiosurgery, H. Radwan, M. Bruce Eisenberg, J. P. S. Knisely, M. M. Ghaly, M. Schulder

Journal Articles

No abstract provided.

Key Perspectives On Auditory Outcomes Following Radiosurgery For Vestibular Schwannoma, Tumor Treating Fields For Glioblastoma, And A Proposed Myelopathy Score For Cervical Decompression Surgery, Intracranial Pressure Monitoring In Diffuse Traumatic Brain Injury., Jonathan H. Sherman, Gordon Li, Jin Mo Cho, Winward Choy, Isaac Yang, Zachary A Smith

Neurological Surgery Faculty Publications

No abstract provided.

Neurosurgery Concepts: Key Perspectives On Intrathecal Fluorescein For Detecting Intraoperative Cerebrospinal Fluid Leak During Endoscopic Endonasal Surgery, Spinal Intraarterial Chemotherapy, Oligoastrocytoma Classification By In Situ Molecular Genetics, And Prenatal Myelomeningocele Closure And The Need For Cerebrospinal Fluid Shunt Placement., Anand V Germanwala, Winward Choy, Jonathan H. Sherman, Sandi Lam, Isaac Yang, Zachary A Smith

Neurological Surgery Faculty Publications

No abstract provided.

Response To The Comments: "Prospective Case Control Evaluation Of Epidural Midazolam For Improving Pain And Ambulation After Microdiscectomy", Muhammad Shahzad Shamim

Section of Neurosurgery

No abstract provided.

Primary Anaplastic Pleomorphic Xanthoastrocytoma In Adults. Case Report And Review Of Literature, Usama Khalid Choudry, Saad Akhtar Khan, Amjad Qureshi, Muhammad Ehsan Bari

Section of Neurosurgery

Background: Pleomorphic xanthoastrocytoma (PXA) classified as a low Grade (WHO II) astrocytic neoplasm. It is known for its relatively favorable prognosis. It most commonly occurs in young adults. Malignant progression in PXA has been frequently reported since its first description in 1979; however, the presentation of a primary anaplastic PXA tumor with an aggressive clinical course in adults is rare especially in the later age group.
Case description: We present a case of primary anaplastic PXA in a 53 year old male that manifested with an early recurrence pattern at 9 weeks. Treatment performed was surgical excision and external beam …

Improved Sensitivity To Fluorescence For Cancer Detection In Wide-Field Image-Guided Neurosurgery, Michael Jermyn, Yoann Gosselin, Pablo A. Valdes, Mira Sibai, Kolbein Kolste

Dartmouth Scholarship

In glioma surgery, Protoporphyrin IX (PpIX) fluorescence may identify residual tumor that could be resected while minimizing damage to normal brain. We demonstrate that improved sensitivity for wide-field spectroscopic fluorescence imaging is achieved with minimal disruption to the neurosurgical workflow using an electron-multiplying charge-coupled device (EMCCD) relative to a state-of-the-art CMOS system. In phantom experiments the EMCCD system can detect at least two orders-of-magnitude lower PpIX. Ex vivo tissue imaging on a rat glioma model demonstrates improved fluorescence contrast compared with neurosurgical fluorescence microscope technology, and the fluorescence detection is confirmed with measurements from a clinically-validated spectroscopic probe. Greater PpIX …

Ependymal Tumors With Oligodendroglioma Like Clear Cells: Experience From A Tertiary Care Hospital In Pakistan, Fauzan Alam Hashmi, Muhammad Faheem Khan, Saad Akhtar Khan, Muhammad Waqas, Muhammad Ehsan Bari, Arsalan Ahmed

Section of Neurosurgery

Background: Ependymal tumors with oligodendroglioma like clear cells have never been reported from Pakistan. We aimed to see the features and outcomes of this rare entity.
Methods: It was retrospective cohort conducted at the Department of Neurosurgery, Aga Khan University from 2003 to 2013. The medical records and radiology of patients with proven histopathology were reviewed. Analysis was done on SPSS 20.
Results: Eleven cases of ependymal tumors with clear cells were found, which equated to 1.5% of the total tumor burden in 11 years. The median age was 49 years. Most common presenting symptom was headache 54.5%. Out of …

Surveillance In The Service Of Safety, Rashid Jooma

Section of Neurosurgery

The World Report on Road Traffic Injury Prevention of 2004 recommended that the newly motorizing countries establish road injury surveillance to define the burden, identify highrisk groups, plan intervention and monitor their impact. Despite its stated importance in the literature, very few examples of sustained surveillance systems are reported from low income countries. This presentation shares the results of an urban RTI surveillance program that has been running for the past 8 years since 2007 in the emergency departments of five major hospitals in Karachi, Pakistan. We describe the process of establishing the road injury surveillance system incorporating a multi-institution …

Bicompartmental Decompressive Craniectomy: Report Of Two Cases, Saad Akhtar, Badar Uddin Ujjan, Muhammad Waqas, Muhammad Waqas Khan Waqas Khan, Gohar Javed

Section of Neurosurgery

A recent study of randomized controlled trials showed favorable outcomes with use of decompressive craniectomy in managing and treating uncontrolled intracranial pressures accompanied with cerebral edema due to trauma. We present the details of bicompartmental decompressive craniectomy on two patients who presented with severe head trauma of supra- and infratentorial pathologies. The surgical management techniques and long-term follow-up are discussed in detail.

Neurofibromatosis Type 2 Patient Presenting With Medulloblastoma, Jan Kalimullah, Abdul Malik Amir Humza Sohail, Rai Shahjehan, Sabeehuddin Siddique, Muhammad Ehsan Bari

Section of Neurosurgery

Background: Neurofibromatosis type 2 (NF2) is an autosomal dominant syndrome with a frequency of 1 in 25,000 live births and a penetrance of almost 100% by the sixth decade of life. The main tumors occurring in NF2 patients are bilateral vestibular schwannomas, other peripheral, cranial and spinal nerve schwannomas, intracranial and intraspinal meningiomas, ependymomas, and gliomas.
Case description: We report the case of a 6-year-old boy who presented with a 1-month history of nausea and recurrent vomiting. Physical examination was positive for ataxic gait and left-sided facial nerve palsy. Family history was positive for NF2 in the patient's father and …

Iv And Ip Administration Of Rhodamine In Visualization Of Wbc-Bbb Interactions In Cerebral Vessels., Zachary Wilmer Reichenbach, Hongbo Li, John P. Gaughan, Melanie B. Elliott, Ronald Tuma

Department of Neurosurgery Faculty Papers

Epi-illuminescence intravital fluorescence microscopy has been employed to study leukocyte-endothelial interactions in a number of brain pathologies. Historically, dyes such as Rhodamine 6G have been injected intravenously. However, intravenous injections can predispose experimental animals to a multitude of complications and requires a high degree of technical skill. Here, we study the efficacy of injecting Rhodamine 6G into the peritoneum (IP) for the purpose of analyzing leukocyte-endothelial interactions through a cranial window during real time intravital microscopy. After examining the number of rolling and adherent leukocytes through a cranial window, we found no advantage to the intravenous injection (IV). Additionally, we …