Nepal Journal of Neuroscience

Non-tuberculous long multi-segment spinal epidural abscess with co-existing giant psoas abscess in an intravenous drug abuser: A rare case report from India

Manish Kumar Mishra — 2023-12-31

In developing countries, Mycobacterium tuberculosis is rampant and it’s the first differential in causation of spinal epidural abscess (SEA) and/or, psoas abscess (PA). This microbiota pertaining to these diseases, is in contrast with that of developing nations, where it is primarily bacterial. The burden of intra-venous drug abusers is very high in India, however there is corresponding rarity of intra-venous drug abuse (IVDA) related SEA/ PA case studies. Even at global scale, there is no fixed recommendation in the surgical management (instrumentation and fusion) of IVDA-SEA subset of patients owing to their low volume and poor-follow-up. In this back-ground authors present their experience of managing an IVDA associated long segment multi-level SEA with giant PA who presented with ASIA Grade-C neurological deficit.

Augmenting Cerebral Perfusion Via Bypass Technique in symptomatic intracranial atherosclerotic disease

Pravesh Rajbhandari — 2023-12-31

In Nepal, acute ischemic stroke (AIS) holds the sobering distinction of being the fifth leading cause of mortality and the third most prevalent source of disability. This underscores a pressing health concern that demands attention and proactive measures to address its impact on public well-being. Nepal is amidst a swift epidemiological shift, witnessing a surge in stroke and noncommunicable diseases due to rapid urbanization, sedentary lifestyles, and poor dietary habits. Urgent measures are essential to address this burgeoning public health challenge.

Clinical and Radiological Prognostication of Diffuse Axonal Injury

Rajanandhan Viswanathan — 2023-12-31

Introduction: We studied the efficacy of the admission neurological status (Glasgow Coma Score - GCS) and the radiological findings (Marshall, Rotterdam and MRI scoring systems) in prognostication of Diffuse Axonal Injury (DAI) using the Glasgow Outcome Score (GOS) to quantify the clinical outcome.

Material and Methods: This is a prospective observational study of 158 consecutive Diffuse Axonal Injury (DAI) patients conducted at Madras Medical College. GCS at admission was taken as the clinical data. Marshall’s, Rotterdam and MRI scores were taken as radiological data. The patients’ GOS at 1 month was taken as clinical outcome.

Statistical Analysis: Statistical analyses were then made to correlate the clinical and radiological data with the one-month outcome of the patients. Statistical analysis was done using the SPSS software – version 16 using statistical tests like Pearson’s coefficient and ANOVA. A p value of less than 0.05 was considered statistically significant.

Results: The admission GCS and MRI grade of DAI showed a statistically significant correlation with the clinical outcome, but the Marshall and Rotterdam scores did not.

Conclusion: Proper neurological evaluation of the patient with GCS score on admission and MRI brain when feasible, with both having a statistically significant correlation with clinical outcome, provide reliable prediction models for prognosticating outcome in DAI patients.

Review Of Cerebral Microbleeds using FAZEKA Classification

Bhanupriya Singh — 2023-12-31

Introduction: Cerebral microbleeds (CMBs), also known as cerebral microhemorrhages, are tiny hypointense foci discovered by susceptibility-weighted (SW) magnetic resonance imaging (MR). CMBs have been interpreted as asymptomatic lesions that may be identified by chance during a brain MRI. This study was done to understand the etiology and various imaging patterns of the cerebral microbleeds on MRI

Materials & Methods: This study was done with a sample size of 325 patients who underwent MRI Brain and diagnosed with CMB at our hospital. Detailed supportive history was taken and data was analysed.

Results: Present study shows strong correlation between CMB’s and white matter changes. CMBs in parietal lobe found to have correlation with cognitive dysfunction. Lacunar infract is the most common subtype associated with the CMB’s

Conclusion: The markers of microangiopathy on MRI brain are CMBs and white matter changes. Correlation of lobar CMBs with periventricular white matter hyperintensities and deep, infratentorial CMBs with deep white matter hyperintensities were found.

Brain Metastases: Outcome related to prognostic indices: Critical Review in a Single institutional Experience

Maneet Gill — 2023-12-31

Introduction: Brain metastases are the most common brain tumour. There are various prognostic indicators which determine the overall outcome and survival of the patient. To study the outcome of the patients of cerebral metastases based on various indices and to correlate the prognostic significance of these indices.

Material and Methods: A total of 123 surgically resected cases of brain metastases from July 2007 to July 2017 were included in the study. The clinical details including the age, gender, clinical features, location of the primary, status of control of primary disease, Karnofsky performance status, number and intracranial location of the metastases were obtained. The follow up period for the study was at least 36 months.

Results: The prognostic factors associated with better survival were KPS > 60 (p value < 0.0001), controlled status of the primary malignancy (p value < 0.0001), age < 50 yrs (p value< 0.0001) and number (<3) of metastases (p value < 0.000). Gender (p value = 0.902), primary site (P = 0.758) and location of intracranial metastases (P = 0.575) had no significant impact on the survival.

Conclusion: Of the various prognostic indices, patients with KPS > 60, well controlled primary malignancy, age <50 yrs. and number of metastases less than 3, were related to statistically significant better prognosis and survival.

Morphometric Assessment of Sellar Turcica: Tertiary Neurocenter study from Nepal.

Suresh Bishokarma — 2023-12-31

Introduction: The sella turcica (ST) is a vital structure located in the median position within the middle cranial fossa and is frequently utilized in cephalometric for assessing craniofacial features. However, there is limited literature available regarding cephalometry of the ST in Nepal. Consequently, this study aimed to establish the normal dimensions of the ST in the Nepalese population and explore the potential difference in radio-morphometric measurement among sexes.

Materials & Methods: This study encompassed a descriptive, cross-sectional chart review conducted at the Upendra Devkota Memorial National Institute of Neurological and Allied Sciences over a three-month period. Morphometric assessment of the ST was performed using computed tomography scans. A single radiologist employed an EV Insite DICOM viewer to measure and record the length, depth, and antero-posterior diameter of the ST. Independent-Samples t-test was employed to compare the means between sexes, and a significance level of p < 0.05 was considered statistically significant.

Results: Among the 385 cases analyzed, 199 were male (51.8%) and 185 were female (48.2%), resulting in a male-to-female ratio of 1.07:1. The age range of the patients was 20 to 87 years, with a mean age of 44.5 ± 18.5 years. The mean dimensions of the sella turcica were determined as 9.32 mm for length, 7.07 mm for depth, and 10.29 mm for the antero-posterior diameter.

Conclusions: The findings of this study indicate that the ST dimensions in the Nepalese population are relatively smaller compared to those reported in various other countries. Additionally, no statistically significant differences were observed in ST dimensions between males and females within the Nepalese population. These results emphasize the importance of considering populationspecific variations when utilizing cephalometric measurements and provide valuable reference standards for future studies and accurate assessment of craniofacial morphology in the Nepalese population.

Open Microdiscectomy or Tubular Discectomy: What Is Better for Lumbar Disc Herniation

Sajag Kumar Gupta — 2023-12-31

Introduction: Many different minimally invasive procedures can be used to treat lumbar disc herniation. In the management of lumbar disc herniation, Open microdiscectomy MD is the gold standard and is used as a benchmark for comparison with more recent techniques like tubular discectomy. The purpose of this study was to assess the complication rates of tubular discectomy and to compare the postoperative outcomes of individuals undergoing tubular discectomy with those undergoing MD.

Material & Methods: A retrospective analysis of 250 patients who underwent single-level lumbar discectomy either by tubular TD or MD between JULY 2018- JUNE 2023 was performed. The differences in the 2 groups' demographics, surgical length, intraoperative blood loss, overall hospital stay, pain score on the visual analogue scale (VAS), Oswestry Disability Index (ODI) score both before and after the procedure, and complications were assessed.

Results: Out of the 250 patients, 130 patients were treated with MD and 120 by tubular discectomy TD. The mean age in MD and tubular TD group was 45.5 and 45.8 years. There was a improvement in VAS and ODI scores at 4 weeks in both the groups. There was a greater reduction of back pain in the TD group at 2 weeks compared to MD group but at 1 month both are comparable. Average surgical time was shorter in MD (71.6 min) as compared to TD group (80.2 min). the Average blood loss was higher (90.2 mL) in MD group as compared to TD group (35.8 mL) (Table 3 ). Length of incision as measured from the surgical scar was 1.7 cm in TD while it was 3.0 cm in MD group. Average hospital length of stay in TD (1.2 days) which was less than MD group (2.1 days). Likewise, MD group patients took 5.9 weeks to return to activity which was higher than the TD group (4.1 weeks). There were 9 cases (6.9%) of dural tear in MD and 10 cases (8.3%) in TD group.

Conclusion: Sciatica caused by disc herniation can be effectively and safely treated with lumbar discectomy, whether it is TD or MD. In comparison to MD, the TD method for treating symptomatic lumbar radiculopathy is superior in that it causes less postoperative back pain, less blood loss, a shorter hospital stay, and a quicker return to work. Despite the learning curve, TD has been demonstrated to be a viable choice for treating lumbar disc herniation in patients who are carefully chosen.

To Evaluate the Efficacy of Internet De-addiction Programme on Perceived Stress and Autonomic Functions in Young Adults

Rajani Bala Jasrotia — 2023-12-31

Internet addiction is characterized by excessive or poorly controlled preoccupations, urges or behaviors regarding computer use and internet access that lead to impairment or distress. The present study was conducted to evaluate the efficacy of internet de-addiction programme on stress and autonomic functions in young adults.

500 young adults (age group 18-35 years), using smartphones and other gadget frequently were asked to answer Kimberley Young’s Internet addiction test (IAT) questionnaire. As per their responses 31 moderates to severely addicted to internet addiction (IAT score 64.51 ± 16.94) were motivated to participate in a comprehensive internet de-addiction programme, based on repeated sessions of psychological counselling and behavioral therapy as advised by an expert clinical Psychologist. Baseline and follow up (after 6 weeks) recording of Heart rate, Blood pressure, Perceived stress scale, IAT, Autonomic functions based on frequency domain HRV were done.

There was significant increase in total power of HRV whereas significant reduction in LF/HF ratio, Perceived stress scores (PSS), Internet addiction scores and average daily mobile usage time after 6 weeks of follow up. It can be concluded from this study that after six weeks of comprehensive sessions based on cognitive behaviour therapy and guiding for self-help approach there were significant decrease in the total daily mobile usages time, internet addiction score, perceived stress score and also simultaneous improvement in symptho-vagal tone and overall autonomic health of participants.

Clinicoradiological Correlation of Serum Procalcitonin Values in Degenerative Lumbar Disc Disease

Abhijeet Bele — 2023-12-31

Introduction: Low back pain (LBP) as a result of prolapsed intervertebral disc is one of the common causes of the morbidity and disability in current population. We assessed any association of inflammatory marker serum procalcitonin in degenerative disc disease.

Materials & Methods: A prospective analytical study carried out at our tertiary care institute over one year from Dec 2021 to Dec 2022 after clearance from institute ethical committee. Total of 68 patients aged 18 to 65 years with low back pain with lumbar disc herniation on MRI imaging were included in the study. Serum procalcitonin levels were assessed using electrochemiluminescence technique on e411 Elecsys 2010.

Results: The median values of serum procalcitonin were higher in early phase of disease tends to stabilising with chronicity of symptoms. There was a positive correlation between mean VAS scores and procalcitonin levels, those patients with higher procalcitonin values clinically had positive straight leg raising test and in the long run required more operative interventions.

Conclusions: Lumbar degenerative disc disease has a strong inflammatory basis and serum values of procalcitonin can be useful objective marker to predict extent of inflammation with prediction of possible clinical course of disease.

Role of short term Video EEG monitoring and MRI in refractory Epilepsy

D.V. Madhavi Kumari — 2023-12-31

Introduction: Inpatient video EEG monitoring is widely used for the diagnosis, seizure classification and pre surgical evaluation of patients with epilepsy. Only few studies have highlighted the role of short term video EEG in the diagnosis of paroxysmal events. The present study was undertaken to identify the role of short term video EEG in refractory epilepsy.

Materials & Methods: Forty patients, attending neurology outpatient department in our institution, during the study period, fulfilling the criteria for refractory epilepsy were included. Short term video EEG and MRI Brain were done for all of them. Outcomes measured were 1) Video recording of epileptic seizures with concurrent ictal pattern or psychogenic non epileptic seizure. 2) Identification of new interictal epileptiform discharges, which were not there in the previous routine EEG. 3) Observation of congruency between EEG and MRI Brain.

Results: Clinical events were recorded in 12.5% of patients - 7.5% had epileptic seizures and 5% had psychogenic non epileptic seizures recorded. Short term video EEG was abnormal in 70% of the patients, whereas previous routine EEG was abnormal in only 30% and these observations were statistically significant. Short term video EEG was useful in diagnostic classification in 70% of the cases. MRI Brain was abnormal in 35% and among them, 30% had lateralized epiletiform discharges and the congruency between them is not statistically significant.

Conclusions: Short term video EEG monitoring could be an initial investigation to sort our more frequent seizure group and proceed to long term VEEG if short term VEEG is inconclusive.

Central Nervous System Melanoma: Report of two cases

Prasanna Karki — 2023-12-31

Primary brain melanomas are exceedingly rare, and metastasis outside of the central nervous system is an uncommon occurrence. The patients initially presented with an intraparenchymal hematoma with associated symptoms. Extensive diagnostic tests did not reveal any tumor-related or vascular patterns contributing to these bleedings. A comprehensive surgical resection was conducted, and the diagnosis of Central Nervous System (CNS) melanoma was confirmed through histological examination. Despite the generally poor prognosis associated with malignant melanomas, the combination of complete surgical resection and emerging therapies is extending overall survival and enhancing the quality of life. In cases where primary brain melanoma is suspected, even in the presence of extracerebral metastasis, aggressive treatment may be a viable consideration.

Unusual presentation of Chronic Subdural hematoma as Isolated Oculomotor palsy

Janam Shrestha — 2023-12-31

Isolated oculomotor palsy (ONP) is an unusual presentation in chronic subdural hematomas (CSDH) and is very rare as an initial manifestation. Most commonly, ONP is caused by ischemic microangiopathy, posterior communicating artery aneurysm, uncal herniation, neoplasia, traumatic and/or any inflammatory conditions. ONP in chronic subdural hematoma is a sign of cerebral herniation that is typically associated with a deterioration of consciousness. We describe a case of chronic subdural hematoma that presented with an isolated ONP.

“Hemorrhagic Transformation Following Thrombolytic Therapy in Acute Ischemic Stroke: A Case Series of 5 Patients”

Kinjal Dave — 2023-12-31

Stroke stands as a global health menace, causing substantial disability and mortality. Timely intervention, specifically within the critical "Golden Hour" following acute ischemic stroke, is imperative. Thrombolytic agents like tissue plasminogen activators (tPA) are pivotal for clot dissolution and blood flow restoration, yet their use introduces the risk of hemorrhagic transformation (HTF).In a recent case series involving five patients receiving thrombolytic therapy for acute ischemic stroke, we illuminate the occurrence of post-treatment HTF, its clinical ramifications, and the intricate challenges in its management. Early intervention in acute ischemic stroke aims to safeguard at-risk brain tissue, with thrombolytic therapy, notably tPA, serving as a primary treatment avenue. However, the associated risk of HTF hovers around 30%–35%, influenced by factors like age, comorbidities, and infarct size. The vulnerable ischemic penumbra, marked by a compromised blood-brain barrier and free radical generation, is particularly susceptible. Treatment decisions, guided by the National Institutes of Health Stroke Scale (NIHSS), pivot on stroke severity assessment, emphasizing the need for vigilant post-treatment monitoring. In conclusion, navigating the delicate balance between the benefits of early thrombolysis and the risks of HTF remains a persistent challenge in optimizing outcomes for acute ischemic stroke patients.

Unusual presentation of trigeminal post-herpetic neuralgia as Hemicrania Continua: A case study

Ashutosh Tiwari — 2023-12-31

Introduction: Cranial post-herpetic neuralgia sometime becomes refractory to medications. Before increasing the medications detailed history of headache phenotype is very important.

Case report: A 41-year-old male developed a herpes infection in the right side first division of the trigeminal nerve two years back before presenting to us. He complained of continuous background dull aching headache (VAS 3 to 4) in the right orbito-fronto-temporal region. Besides this he used to experience sharp shooting severe pain (VAS 8 to 9) for one to two hours, occurring two to three times a day every five to six days for the last two years in same distribution. Episodes of exacerbation were associated with cranial autonomic symptoms (CAS), including right-side eye redness, lacrimation, and nasal congestion. His examination revealed nothing additional than allodynia in the same distribution. His MRI brain revealed no significant abnormality. Different medications were tried but in vain. He was started on Indomethacin to which he responded dramatically.

Discussion: Non responsive cases of PHN form a refractory group and might be subjected to unnecessary medications or interventions. Secondary hemicrania continua have been reported due to different causes other than herpes. So, after ruling out secondary causes indomethacin challenge should be the next step in the diagnostic workup.

Microsurgery of Brainstem Cavernoma: Challenges and Outcomes

Kumar Paudel — 2023-12-31

Cavernous malformation of brainstem is at increased risk of hemorrhage compared to supratentorial cavernomas. Increased morbidity associated with brainstem cavernoma (BCs) is defined by the inherent eloquence of the surrounding structures. At present watchful waiting, microsurgical resection and gamma knife surgery are the treatment modalities for symptomatic brainstem cavernoma. However, in the resource limited settings microsurgical excision by selecting an appropriate corridor can help in gross total removal in the meantime improving the neurological deficit and patient satisfaction. In this case series we have reviewed cavernomas of midbrain and pons, the technical difficulty with its management and its outcomes.