Nepal Journal of Neuroscience 2021-09-01T07:29:26+00:00 Prof Amit Thapa Open Journal Systems <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> Sub-specialty in neurosurgery: Time has come for Nepal 2021-08-16T17:02:40+00:00 Amit Thapa <p><em>With over 90 practicing neurosurgeons in the country, should we be developing sub-specialty in neurosurgery? </em></p> <p>The number of trained manpower has risen steadily, since neurosurgery was first practiced in Nepal in 1961.<sup>1</sup>Though we are halfway to the milestone of achieving a ratio of 1 neurosurgeon for every 1 lac population, the situation here is much better than in other Sub-Saharan African and south east Asian countries.<sup>2</sup> All the seven states have now neurosurgeons working in its hospitals, though most are still concentrated in the capitals and major towns.</p> <p>Recently for the last five years, despite of lack of training opportunities for sub-specialty in the country, we have seen young neurosurgeons getting trained in skull base, spine, minimally invasive or endoscopic neurosurgery, functional neurosurgery, pediatric neurosurgery and vascular neurosurgery from abroad. There is a variation in nature and period of training, ranging from observership of a few weeks to fellowship of over a year. The interest seems to be getting stronger as the facilities and complexities of cases are increasing. In such scenarios, rather than few individuals we need units or teams offering these sub-specialized services from key centers and start supervised systematic training for the interested.</p> 2021-09-01T00:00:00+00:00 Copyright (c) 2021 Nepalese Society of Neurosurgeons (NESON) Intra-diploic epidermoid cyst: An iceberg lesion 2021-06-10T10:23:35+00:00 Prashant Punia Ashish Chugh Sarang Gotecha <p><strong>Introduction: </strong>Intraosseous epithelial inclusion cysts of the skull, presenting as lytic defects, constitute a very small percentage of the primary intracranial tumours. The case is presented by virtue of not only the rarity of the variant but also to highlight the importance of timely intervention by a neurosurgeon after adequate investigation and in a tertiary care setting.</p> <p><strong>Case Report: </strong>A 45 year old female patient presented to the local Primary Healthcare Centre(PHC) with a small scalp swelling in the occipital region. . Intraoperative identification of intracranial extension was made by the surgeon as inferior margin of the swelling couldn’t be reached and also by palpation of the huge bone defect following which the procedure was abandoned midway and patient was referred to our centre for further management.</p> <p><strong>Imaging: </strong>Contrast Enhanced Computerised Tomograhy(CECT) revealed a well defined, mixed density lesion with hypodense and an isodense component in right occipital region. Lesion was measuring 4.2(Cranio caudal) x 3.3(Antero posterior) x 3.6( transverse) cm. A sharp marginated bone defect was noted involving both the outer and inner tables of the occipital bone.</p> <p><strong>Operative management: </strong>Lesion was approached through a right occipital craniotomy wherein the margins of bone defect were nibbled away to gain a wide access to the lesion. Pearly white, flaky contents of the lesion along with capsule were identified and excised completely.</p> <p><strong>Discussuion:</strong> Intradiploic epidermoid cysts are very rare, accounting for &lt;3% of all intracranial epidermoid cysts.(5) These cysts grow very slowly and usually present as painless bony swelling under the scalp.</p> <p><strong>Conclusion: </strong>Cranial epidermoid is a fairly common entity and intradiploic variant of the same isnot uncommonly seen in neurosurgical practise. These lesions may present as a small scalp lesion which should not be judged based on its apparent size as these lesions are not infrequently known to have a bigger intracranial extension</p> 2021-09-01T00:00:00+00:00 Copyright (c) 2021 Nepalese Society of Neurosurgeons (NESON) Dyke-Davidoff-Masson Syndrome with crossed cerebellar atrophy 2021-06-06T16:42:08+00:00 Rohit Kumar Deepak Kumar Himanshu Mishra Sanjay Kumar Suman Umakant Prasad <p>Dyke-Davidoff-Masson Syndrome (DDMS) is a rare neurological condition characterised clinically by recurrent seizures, facial asymmetry, hemiplegia and mental retardation likely due to foetal or early childhood cerebral insult. We describe the MRI findings of DDMS in a 10-year-old male child. MRI brain revealed right cerebral atrophy, ipsilateral thickening of calvarium, right lateral ventricular dilatation, hyper-pneumatisation of frontal sinus, and contralateral cerebellar atrophy which are consistent with DDMS.</p> 2021-09-01T00:00:00+00:00 Copyright (c) 2021 Nepalese Society of Neurosurgeons (NESON) Recurrent stroke in varicella zoster associated vasculopathy 2021-06-10T10:14:28+00:00 Pradeep Kumar Maurya Ajai Kumar Singh Ashutosh Tiwari Abdul Qavi <p>Varicella zoster virus (VZV) is well known for its neurotropism, primary infection and reactivation after variable latency periods. After reactivation from spinal or cranial nerve ganglia, viruses can affect the central nervous system and cranial vasculature via transaxonal migration followed by transmural spread from the adventitial layer to the intima. Stroke can occur following primary infection by VZV (varicella) or after reactivation (zoster). These infectious vasculitides by VZV can lead to unifocal or multifocal ischemic and hemorrhagic stroke either after cranial nerve or spinal dermatomal zoster. Usual difference between immunocompetent versus immunocompromised individuals is involvement of unifocal large vessel vasculopathy in the former while multifocal small vessel in later. This vasculopathy in some cases may be progressive leading to recurrent stroke even after antiviral treatment. Diagnosis becomes challenging and needs a high degree of suspicion in immunocompetent, younger individuals, in absence of rash and when there are comorbidities. We report a case of elderly immunocompetent women, who developed multifocal infarcts followed by ventricular and subarachnoid haemorrhage after thoracic varicella zoster. Diagnosis was confirmed by the presence of anti-VZV IgG antibodies in the cerebrospinal fluid. In view of the diverse clinic-radiological spectrum of VZV vasculopathy, early recognition of this clinical entity is warranted for improved outcome.</p> 2021-09-01T00:00:00+00:00 Copyright (c) 2021 Nepalese Society of Neurosurgeons (NESON) Giant cavernoma mimicking a right frontal tumor 2021-06-10T10:13:51+00:00 Louncény Fatoumata Barry El hadji Cheikh Ndiaye Sy Mohameth Faye Momar Code Ba <p>Cavernomas account for 9 to 16% of cerebrovascular malformations with a prevalence of 0.5% in the general population. We report a case of a large frontal cavernoma mimicking a frontal tumor and revealed by epileptic seizures. We report a 40-year-old man, without any particular history, received in consultation for tonic-clonic generalized convulsive seizures evolving for 5 years with a normal clinical examination on admission. Cerebral CT scan revealed a large right frontal lesion suggestive of a brain tumor, requiring surgical removal after persistent seizures despite dual antiepileptic therapy. The evolution was favorable at one year with the total cessation of the convulsive seizures without neurological after-effects. In conclusion, giant brain cavernomas are rare lesions and may be mistaken for a brain tumor.</p> 2021-09-01T00:00:00+00:00 Copyright (c) 2021 Nepalese Society of Neurosurgeons (NESON) Carotid stenting in Nepal: Our experience with two cases of carotid stenosis 2021-05-14T07:41:02+00:00 Pravesh Rajbhandari Saujanya Rajbhandari Anish Neupane Tariq Martin Basant Pant <p>Carotid artery stenosis is one of the important risk factors for stroke. Carotid endarterectomy and carotid artery stenting are the available treatment options for managing carotid artery stenosis patients. The technology shift towards carotid artery stenting is promising due to its less invasive approach. Carotid artery stenting has become an alternative for surgically high-risk patients and high carotid lesions (lesions located at or above the second cervical vertebra). Here, we present two cases with carotid artery stenosis who were successfully treated with open-cell type carotid stent with distal filter embolic protection device.</p> 2021-09-01T00:00:00+00:00 Copyright (c) 2021 Nepalese Society of Neurosurgeons (NESON) Sturge-Weber syndrome: Clinico-neuroradiological features and treatment profile 2021-06-10T10:14:31+00:00 Anirban Chatterjee Malay Kumar Sinha <p><strong>Introduction: </strong>Sturge Weber syndrome (SWS) is a rare, nonhereditary genetic disorder. SWS belongs to a diverse group of Neurocutaneous disorders. A somatic mutation in the early development of cells in SWS patients causes the formation of a congenital capillary vascular malformation. SWS is characterized by nevus flammeus on the face (also called Port-Wine Birthmark), brain (leptomeningeal angioma), and eyes (glaucoma).</p> <p><strong>Methods and Materials: </strong>We present three patients diagnosed with Sturge Weber syndrome who attended a teaching hospital between 2013 to 2016. The clinical, neuroradiological features and treatment of SWS patients were reviewed retrospectively from medical records.</p> <p><strong>Results: </strong>Two males and females with SWS were reviewed. The facial nevus flammeus was unilateral in one patient and bilateral in two patients. The extensive nevus flammeus including the face, trunk, and upper limb was found in one patient. Epilepsy, neurodevelopmental delay, and intellectual disability were the most common presentation in the series. Episodic hemiparesis was manifested in one patient. Levetiracetam and oxcarbazepine, either single or combined, were used in every SWS patient (n=3). Six months seizure-free was obtained in a patient with SWS with combined anticonvulsant therapy. </p> <p><strong>Conclusion: </strong>Drug-refractory and early-age epilepsy is associated with lower intelligence level that consequently affects poor social skill and quality of life in the patients with SWS. Sudden or gradual loss of vision is also a threat for SWS patients. Diagnosis at birth or during early age, multidisciplinary intervention, and follow-up is a must to improve absolute outcomes in the patients with SWS.</p> 2021-09-01T00:00:00+00:00 Copyright (c) 2021 Nepalese Society of Neurosurgeons (NESON) Remote extradural hematoma after supratentorial brain tumor surgery: A rare complication of a routine surgery 2021-07-01T13:36:19+00:00 Prashant Punia Ashish Chugh Sarang Gotecha <p><strong>Background: </strong>Hemorrhages in the surgical cavity post resection of tumor aren’t uncommon and neurosurgeons are well versed with this entity, however occurrence of an Extra Dural Hematoma(EDH), that too at a site remote to the surgical cavity, is rare. The study presents 3 cases of post operative remote site EDH after tumor resection with review of literature&nbsp; and an attempt to define and discuss the variables which play a role in determining the occurrence, extent and prognosis of the same.</p> <p><strong>Methods:</strong> The study investigated 601 patients who underwent tumor resection in the Department of Neurosurgery, Dr D Y Patil Hospital, from January 2017 to December 2019. All patients had a normal coagulation profile preoperatively. Postoperative remote EDH occurred in 3 patients whose data was examined closely in terms of age, sex, location, final diagnosis and treatment.</p> <p><strong>Results:</strong> Of the 601 patients who underwent tumor resection from Jan 2017 to Dec 2019, a total of 3 patients in our study were found to have a post-operative remote site EDH. Two of these patients were male and 1 female. The age range was 35 to 46 years with a mean of 41 years. Neither did any of these patients have a pre-existing hydrocephalus nor were they subjected to a CSF diversion procedure preoperatively. All 3 patients developed EDH on the ipsilateral side wherein 2 of our patients had a hematoma in the ipsilateral frontal region anterior to the surgical cavity while 1 patient developed hematoma in ipsilateral parietal region posterior to surgical cavity. Hematomas were unilateral with no extension to opposite side. Two patients had to be re-operated in an emergency setting while one patient was conservatively managed. &nbsp;</p> <p><strong>Conclusion:</strong> In patients with an expected volume loss via large tumor size, excess blood and CSF loss and a large craniotomy, remote EDH may develop and the&nbsp; neurosurgeon must have a high index of suspicion for this entity</p> 2021-09-01T00:00:00+00:00 Copyright (c) 2021 Nepalese Society of Neurosurgeons (NESON) Research and publication ethics in developing countries 2021-06-11T01:03:06+00:00 Mohan Raj Sharma Namita Ghimire <p>The scientific validity of any project relies heavily on the ethically conducted and published research work. Conducting good quality research and publishing it in a scholarly, peer-reviewed journal is the ultimate dream of any researcher. However if not done without any research and publication ethics, the work will be counterproductive. Fortunately, there are several publications on ethics of research and publication guiding an early-stage researcher to follow the underlying principles. Research ethics include upholding the basic ethical principles of human research, namely, respect for persons, beneficence, and justice. Publication ethics involve not committing scientific misconduct, resolving authorship disputes, and avoiding simultaneous submission and duplicate publication. Repercussions of unethical research and publications are often unforgiving. Researchers in developing countries face unique challenges in this regard. However, at no cost should these principles be ignored. This will promote the development of a healthy research and publication culture, so desperately needed in these populations. Researchers, sponsors, ethical boards, publishers, and editors should work hand-in-hand to safeguard the research and publication integrity. In this review, issues surrounding research and publication ethics relevant to developing countries will be discussed.</p> 2021-09-01T00:00:00+00:00 Copyright (c) 2021 Nepalese Society of Neurosurgeons (NESON) Calendar of Events (from October 2021 - December 2021) 2021-08-24T15:34:06+00:00 Amit Thapa <p><strong>Calendar of Events (from October 2021 - December 2021)</strong></p> 2021-09-01T00:00:00+00:00 Copyright (c) 2021 Nepalese Society of Neurosurgeons (NESON) A prospective study of the relation of patient-reported outcome measures with lumbar disc surgery for herniated lumbar disc 2021-05-14T06:06:40+00:00 Hitendra S Naik Samarendra Nath Ghosh Pradeep Saha Parthasarathy Biswas <p><strong>Introduction: </strong>The aim of this 6-month prospective study was to seek out the factors affecting surgical outcome, predictors of treatment response and their correlates in open discectomy for herniated lumbar disc.</p> <p><strong>Methods and Materials: </strong>Eighty patients who fulfilled the required criteria were chosen. Socio-demographic, clinical data proforma, Visual Analogue Scale for pain (VAS), Japanese Orthopedic Association (JOA) Scale for subjective and objective pain related QoL, General Health Questionnaire-12 (GHQ-12) for screening mental health, Short Form-36 (SF-36) Health Survey for assessing Health-related Quality of Life (HRQOL) and Montgomery Asberg Depression Rating Scale (MADRS) for measurement of clinical depression were used at the preoperative stage and reassessed again at 1 month, 3 months and 6 months post-discectomy.</p> <p><strong>Results: </strong>Postoperatively, VAS and JOA Scale scores continued to show improvement at each follow up (p&lt;0.001). Majority of the SF-36 subscales showed significant improvement at 3-months and 6-months of the postoperative period. A significant correlation was seen between the duration of pain symptoms and depression scores at 6 months (rho 0.301 p&lt;0.01). Baseline VAS score had a significant negative correlation with baseline Physical Functioning and General Health scores at 6 months. The duration and severity of pain symptoms before surgery predicted the depression scores at 6 months (adjusted R square 0.056 p&lt;0.001) postoperatively.</p> <p><strong>Conclusion: </strong>The discectomy procedure resulted in significant improvement in baseline subjective pain symptoms and overall HRQOL. Greater the duration and intensity of pain symptoms at baseline, greater was the depression scores and lesser was the SF-36 physical functioning and general health at 6-month postoperative period.</p> 2021-09-01T00:00:00+00:00 Copyright (c) 2021 Nepalese Society of Neurosurgeons (NESON) Sulcal FLAIR hyperintensity - Finding beyond meningitis 2021-05-20T05:01:45+00:00 Aishwerya Singh Sweta Krishnan Ruchi Gupta Samiullah Hasan <p><strong>Introduction: </strong>The aim of this study was to enumerate the causes of Fluid-attenuated inversion recovery (FLAIR) hyperintensity in the sulcal space which could be due to cerebrospinal fluid (CSF) or non-CSF related pathologies.</p> <p><strong>Methods and Materials: </strong>This is an observational retrospective study done in 100 patients in the department of Radio-diagnosis of Patna Medical College and Hospital, Patna from September 2019 to September 2020.</p> <p><strong>Results:</strong> The mean age of patients was 40.13 +/- 13.88 years (Range 19 to 75 years). Male to female ratio was 1.32:1.00 (57:43). The most common cause of FLAIR sulcal hyperintensity was infection in 66% cases followed by meningeal tumor deposits in 16%, vascular cause in 6%, subarachnoid hemorrhage in 5%, mass effect in 5%, dermoid rupture in 1% and hyperoxygenation in 1%.</p> <p><strong>Conclusion:</strong> Presence of sulcal hyperintensity on FLAIR images is a very strong sign to an underlying brain pathology. A keen observation of the same on FLAIR sequence in association with other findings can increase diagnostic confidence and thus lead to better patient care.</p> 2021-09-01T00:00:00+00:00 Copyright (c) 2021 Nepalese Society of Neurosurgeons (NESON) Cranial autonomic symptoms in episodic migraine: An observational study from headache clinic of a tertiary care center of North India 2021-07-04T01:39:04+00:00 Abdul Qavi Pradeep Kumar Maurya Rajani Bala Jasrotia Ajai Kumar Singh Dinkar Kulshreshtha Arshi Ansari Anup Kumar Thacker <p><strong>Introduction:</strong> The presence of cranial autonomic symptoms (CAS) is a hallmark of trigeminal autonomic cephalalgia like cluster headache but their presence in migraine is also not uncommon. Like in trigeminal autonomic cephalalgias, the activation of the trigeminal autonomic reflex pathway is thought to be the possible explanation of the presence of cranial autonomic symptoms in migraine also. Previous studies suggested that around half of the patients of migraine suffer from these symptoms. The aim of our study was to observe the frequency of cranial autonomic symptoms in episodic migraine patients along with their clinical and autonomic characteristics.</p> <p><strong>Methods and Materials: </strong>Fifty patients of episodic migraine attending the headache clinic of Dr. RMLIMS, Lucknow and fulfilling the diagnostic criteria of International classification of headache disorder third edition beta were randomly selected and enrolled in the study. The detailed interview regarding presence of cranial autonomic symptoms was recorded along with the clinical characteristics, demographic features and autonomic profile of the migraine patients.</p> <p><strong>Results:</strong> About three-fourth (72%) of the patients were females. The mean age of study participants was 27.7±8.3 years. A considerable number of patients (54%) had a long duration (5-10 years) of illness and 70% of patients had severe headaches. Photophobia was the most common (88%) associated clinical symptoms while lacrimation was the most common (56%) cranial autonomic symptom in migraine patients. Among 50 patients of migraine 74% of patients were having at least one cranial autonomic symptoms.</p> <p><strong>Conclusion:</strong> Cranial autonomic symptoms are common in patients of episodic migraine. More severe headache is more likely to be associated with the development of cranial autonomic symptoms.</p> 2021-09-01T00:00:00+00:00 Copyright (c) 2021 Nepalese Society of Neurosurgeons (NESON) Factors affecting outcome of decompressive hemicraniectomy in malignant middle cerebral artery infarction 2021-06-10T08:36:14+00:00 Sagar Koirala Shreeram Bhandari Subash Lohani <p><strong>Introduction: </strong>Decompressive Hemicraniectomy (DHC) is a standard surgical management of malignant MCA (MMCA) infarction. This study was conducted to review the outcome of surgery and to find out factors associated with favorable outcomes at a tertiary level neurosurgery referral centre.</p> <p><strong>Methods and Materials: </strong>This is a retrospective study conducted over a period of three years from 2017 to 2019. Patient charts were reviewed for variable like age, sex, timing of surgery, GCS at presentation, length of ventilation, length of ICU admission and length of hospital stay. Primary outcome measure was GOSE: favorable (&lt;=4) and unfavorable (&gt;=5). SPSS version 23 was used for analysis.</p> <p><strong>Results: </strong>A total of 28 patients underwent DHC out of which 21 patients were available for analysis. Mean age of patients was 58.62 years. Mean GCS on arrival was 11.86. Mean interval duration between event and surgery was 51.88 hours. Mean duration of ventilation was 4.43 days. Mean length of ICU stay was 5.95 days. Mean hospital stay was 22.33 days. Mean GOSE was 2. Mean age was significantly lower in patients with favorable GOSE. Early surgery had better mean GOSE which was not significant statistically.</p> <p><strong>Conclusion: </strong>Patients with age less than 50 years have favorable GOSE despite MMCA infarction if decompressive hemicraniectomy is performed to accommodate brain swelling. Early surgery at presentation rather than waiting for deterioration might improve the outcome.</p> 2021-09-01T00:00:00+00:00 Copyright (c) 2021 Nepalese Society of Neurosurgeons (NESON) Role of magnetic resonance imaging in prediction of outcome in traumatic diffuse axonal injury: A single-centre observational study 2021-08-16T17:02:47+00:00 Suraj Thulung Nikunj Yogi <p><strong>Introduction: </strong>Incidence of diffuse axonal injury has been estimated at 40-50% of hospitalizations. Recently, much interest has been directed towards the potential of newer imaging sequences of magnetic resonance imaging to investigate diffuse axonal injury (DAI) and to prognosticate the outcome. In this study, we correlated the magnetic resonance imaging grades of diffuse axonal injury with clinical outcome in terms of Glasgow Outcome Scale (GOS).</p> <p><strong>Methods and Materials:</strong> A hospital based observational study was carried out at Upendra Devkota Memorial National Institute of Neurological and Allied Sciences, Kathmandu in 69 patients of diffuse axonal injury between November 2017 to November 2018. Data was collected on patient and trauma characteristics, as well as neurological assessment and MRI findings. Outcome was assessed as favourable and unfavourable GOS for various MRI grades of diffuse axonal injury.</p> <p><strong>Results:</strong> There were 21.74%, 42.03% and 36.23% of cases with grade I, II and III diffuse axonal injury respectively. There were 0 (0%), 2 (11.8%) and 15 (88.2%) cases of MRI grade I, II and III diffuse axonal injury in favourable GOS group and 15 (28.8%), 27 (51.9%) and 10 (19.2%) cases of MRI grade I, II and III diffuse axonal injury in unfavourable GOS group (p=0.00).</p> <p><strong>Conclusion: </strong>This study showed that there was a significantly higher chance of unfavourable outcome with increasing MRI grades of diffuse axonal injury.</p> 2021-09-01T00:00:00+00:00 Copyright (c) 2021 Nepalese Society of Neurosurgeons (NESON)